Every finding on record at Avir at Burnet

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #36, Resident #49, and Resident #54) reviewed for infection control. CNA B did not change contaminated gloves prior to Resident #49's repositioning; contact with clean supplies; and she did not wash her hands after removing gloves post perineal care. ADON did not sanitize her hands between changing gloves and before exiting a room while performing wound care on Resident #54. LVN A did not sanitize hands after removing gloves and touching medication cart and documenting on the computer after completing blood sugar check on Resident #36. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.Findings included: A. Record review of Resident #49's face sheet, dated 04/27/2026, reflected [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included: malignant neoplasm of unspecified part on bronchus or lung (a primary, cancerous tumor originating in the airway or lung tissue where the specific lobe or laterality is not documented), anxiety disorder, and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out daily tasks). Record review of Resident #49's annual MDS assessment, dated 03/12/2026, reflected BIMS level of 5, severe cognitive impairment, with care areas triggered: urinary incontinence. Record review of Resident #49's comprehensive care plan, dated 11/05/2021, reflected a focus ADL self-care performance deficit with interventions included Toilet use: resident need extensive assistance with toilet use. Provide physical assistance with transfer, peri-care, adjusting clothing and hygiene as needed. Provide incontinence care as needed. Observation of Resident #49's perineal care on 04/27/2026 at 12:24 p.m. revealed CNA B did not change gloves between cleaning the front and back perineal (area between the anus and the genital organs) areas of Resident #49 and touched Resident #49's clothes, body, bedding and clean incontinence brief while repositioning her with contaminated gloves. CNA B removed contaminated gloves after completing Resident #49's perineal care and did not wash hands before lowering resident's bed, positioning call light at Resident #49 reach and opening resident's door. During an interview on 4/27/2026 at 12:34 PM, CNA B stated that she had an in-service on hand hygiene and infection control sometimes in last 6 months and she was supposed to change gloves between front and back perineal area and wash hands with soap and water after taking gloves off and before leaving Resident #49's room. She stated that not washing hands and changing gloves according to the facility's policy could lead to cross contamination and infection control issues that could negatively affect residents' health. CAN B stated she forgot to change gloves between front and back perineal area and wash hands with soap after taking gloves off. B. Record review of Resident #54's admission record, dated 04/28/2026, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of pressure ulcer of right buttock, stage 4 (the most severe type of pressure ulcer (bedsore), featuring full-thickness skin loss with extensive destruction, exposing muscle, tendon, or bone), pressure ulcer of sacral region, stage 2 (partial-thickness skin loss), pressure ulcer of right hip, stage 2, pressure induced deep tissue damage of right heel, and Parkinson (a progressive neurodegenerative disorder affecting dopamine-producing neurons in the brain). Record review of Resident #54's baseline care plan, dated 04/28/2026, reflected a focus: wound care management with indicated interventions: Provide wound care per treatment order. Monitor ulcer for signs of infection. Record review of Resident #54's orders revealed an order, dated 04/23/2026, right ischium stage 4 pressure ulcer: cleanse with normal saline, pat dry with gauze, apply collagen, particles, calcium alginate, and secure with bordered foam daily. Record review of Resident #54's wound care notes, dated 04/23/2026, right ischium with exposed tissue.with exudate (fluid) amount: moderate. Exudate description: serosanguineous (a thin, watery wound discharge that is light red or pink, containing both blood and serum). Observation of Resident #54's wound care on 04/28/2026 at 1:41 p.m., revealed ADON washed her hands before starting wound care, applied PPE and used a clean gauze for cleaning right ischium stage 4 pressure ulcer wound, applied the collagen powder to the wound bed, and secure with bordered foam dressing without dating it. ADON removed gloves, discarded used supplies, picked up treatment scissors from Resident #54's table and did not wash her hands before exiting the room. She used a hand sanitizer dispenser outside the room. She did not sanitize the treatment scissors before putting them into the treatment cart. During an interview on 04/28/2026 at 1:45 PM, ADON stated that she had received a specialty training on infection control last month when she became an infection preventionist. She stated that she was responsible for the infection prevention and control program. She stated that according to facility's policy hand hygiene should be performed before entering resident's room, between gloves change, and before exiting resident's room. ADON stated that she was not aware of the requirement to date a dressing as soon as it was documented in treatment notes. She stated that she had a wound care module at hire and quarterly. ADON stated that a corporate nurse observed her skills for following infection prevention techniques during wound care. She stated that if proper hand hygiene and infection control policy were not followed, it could negatively affect residents due to cross contamination. She stated that in-service on hand hygiene and infection control was provided to staff on continues basis and nursing management including infection preventionist were responsible for monitoring staff followed the proper protocol for hand hygiene and infection control. ADON stated that she was nervous and forgot to wash her hands before exiting Resident #54's room. C. Record review of Resident #36's admission record, dated 04/08/2026, reflected a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus with hyperglycemia (occurs when insulin resistance and inadequate insulin production cause high blood sugar levels), hypertensive heart disease with heart failure (chronic, uncontrolled high blood pressure causes the heart muscle to weaken, limiting its ability to pump blood effectively), and chronic obstructive pulmonary disease (a progressive, treatable lung disease that causes severe breathing difficulties by blocking airflow). Record review of Resident #36's quarterly MDS, dated [DATE], reflected a BIMS score of 11, moderate cognitive impairment. Record review of Resident #36's comprehensive care plan, dated 05/28/2025, reflected Resident has a diagnosis of diabetes is at risk for low and high blood sugar episodes and complications related to disease process and interventions: Monitor accu checks as ordered. Notify Md or results less than 70 or greater than 400 mg/dl. During an observation on 04/29/2026 at 11:27 a.m., LVN A performed blood glucose monitoring test on Resident #36, she lanced (using a small needle [lancet] and device to prick the side of a fingertip) Resident #36's finger and when received an error message, she reached for the new supplies removing just one glove and touched her medication cart with contaminated glove. She did not sanitize her hands between gloves change. LVN A got a new test strip, inserted it in glucometer (a portable, medical device used to measure blood sugar level via a finger-prick blood sample) and after obtaining the blood sugar level she properly discarded the used lancet and removed the gloves, but did not sanitize her hands before documenting the test results on the computer. During an interview on 04/29/2026 at 11:26 p.m., LVN A stated she was trained on handwashing and infection control policy in last 6 months. She stated she recalled not sanitizing her hands between changing gloves during the blood sugar check on Resident #36. LVN A stated that not washing or sanitizing hands after removing gloves and touching medication cart with contaminated hands/gloves could introduce bacteria to the residents. During an interview on 04/28/2026 at 02:42 p.m., the DON stated he expected staff to follow infection control and hand hygiene policy when performing medical procedures or direct care to a resident. He stated that nursing management, including DON, ADON and infection preventionist, was responsible for monitoring staff following facility infection control policies and providing staff in-services on infection control to protect residents and prevent the cross contamination. He stated that hand washing should be completed before going to resident's room, after completing incontinent care, wound care or any other invasive medical procedures, and before exiting the room. He stated that hand hygiene should be performed between gloves' changes. He stated that if not following proper infection control policy, it could negatively impact residents due to their vulnerable status. During an interview on 04/29/2026 at 3:50 p.m., RVP stated she expected staff to follow all infection control protocols when performing peri care, medication administration, and wound care. She stated that not following infection control during medical procedures and direct resident care could lead to cross contamination. Review of facility policy titled Handwashing/hand hygiene, dated October 2010, reflected: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene: c. after contact with blood, body fluids, or contaminated surfaces;d. after touching a resident;g. immediately after glove removal.5. The use of gloves does not replace hand washing/hand hygiene. Review of facility policy titled Wound care, dated 2001, reflected: 19. Disinfect overbed table. 21. Wipe reusable supplies with alcohol as indicated (i.e., outside of containers that were touched by unclean hands, scissor blades, et.). 23. Wash and dry your hands thoroughly.

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 sanitation. The facility failed to properly label food containers stored in refrigerator with contents and use by date. This failure could place residents at risk of foodborne illness.Findings include: During initial kitchen observation and interview on 04/27/2026 at 6:10 AM revealed the following:*five small single serve condiment containers holding diced green onions that were not labeled or dated in the walk in refrigerator.*two bags of shredded lettuce that had expired on 04/22/2026.DM removed and disposed of these items and stated the containers were for garnish the previous evening, but they should have been labeled. She stated that the lettuce should have been removed. In an interview on 4/29/2026 at 9:30 AM with DM she stated that she frequently in-services her staff on food storage and handling. She stated that all containers should be labeled with the contents and use by date. She stated that expired food items should be removed from the kitchen as they could be used to prepare meals and cause the residents to become sick. In interview on 4/29/2026 at 9:37 AM with FA she stated that she was frequently in-serviced on food storage and handling. She stated that food items should be labeled with what they are as well as use by date. She stated if food items are used after they are expired it could make the residents sick. In an interview on 4/29/2026 at 9:40 AM with CK she stated that she was frequently in-serviced on food storage and labeling. She stated that food items should be labeled with what they are as well as use by date. She stated if food items are not labeled with a use by date they would not know when the food expired and if expired items were used to prepare food the residents could become sick. In an interview on 4/29/2026 at 12:49 PM with RVP, she stated that food items should be labeled with what they contain and the use by date. She stated that if items are used past their use by date and it could cause food borne illness. In interview on 4/29/2026 at 1:05 PM with the DON, he stated to his knowledge food storage containers are to be labeled with their contents and the use by date. He stated if items are used after the use by date residents could end up with food borne illness. Record review of facility policy, Food Receiving and Storage, revised November 2022 states that, food shall be received and stored in a manner that complies with safe food handling practices. In section labeled Refrigerated/Frozen storage it states, 1. All foods in the refrigerator or freezer are covered, labeled and dated ( use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 2 of 5 residents (Resident #3 and Resident #6) reviewed for PASARR Level I screenings.1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #3 and Resident #6. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis major depressive disorder and bipolar disorder was present upon admission.2. The facility did not complete a 1012 form to update Resident #3 and Resident #6's PASARR Level 1 with the diagnosis.These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs. Findings included:1.Record review of Resident #3's undated face sheet indicated an [AGE] year-old male who admitted to the facility on [DATE]. Resident #3 had diagnoses of unspecified dementia ( diagnosis used when symptoms of cognitive decline are present, but the underlying cause cannot be clearly identified), major depressive disorder (serious, common mental health condition characterized by persistent, severe low mood, loss of interest in activities, and low energy lasting at least two weeks), and hypertension (high blood pressure).Record review of Resident #3's MDS record dated 04/24/2026 indicated he had a diagnosis of depression which was labeled under psychiatric/mood disorders.Record review of Resident #3's care plan indicated a diagnosis of major depressive disorder. The care plan stated resident would not have any signs of anxiety or depression through the review date. Record review of Resident #3's level 1 PASARR dated 03/21/2026 indicated that Resident #3 did not have evidence of a mental illness.2.Record review of Resident #6's undated face sheet indicated a [AGE] year-old female who admitted to the facility on [DATE]. Resident #6 had diagnoses of bipolar II disorder (chronic mental health condition characterized by recurrent, severe depressive episodes alternating with milder, elevated mood periods called hypomania), depression (serious, common medical illness causing persistent sadness, loss of interest, and functional impairment), anxiety disorder (mental health conditions characterized by excessive, persistent fear or worry that interferes with daily life), and unspecified dementia (diagnosis used when symptoms of cognitive decline are present, but the underlying cause cannot be clearly identified). Record review of Resident #6's MDS record dated 02/04/2026 indicated she had a diagnosis of anxiety, depression and bipolar.Record review of Resident #6's care plan indicated a diagnosis of anxiety disorder, depression and bipolar disorder. The care plan stated resident would show decreased episodes of anxiety and depression through the review date.Record review of Resident #6's level 1 PASARR dated 07/21/2023 indicated that Resident #6 did not have evidence of a mental illness.An interview on 04/29/2026 at 11:03AM was conducted with MDS A who reported she had worked at the facility since 2021. MDS A stated she had received training on PASARR. MDS A stated that PASARR should be completed within 72 hours upon admission. MDS A stated that she was responsible for checking if the PASARRs are correct. MDS A stated that diagnoses such as bipolar, schizoaffective, cerebral palsy are all diagnoses that would indicate a positive level 1 PASARR. She stated the local authority would have been notified of a presumptive positive PASARR and they would come out and conduct a level 2, which was knows as a PE. MDS A stated that if a resident's PASARR was inaccurate then the resident could not receive services that they are eligible for. MDS A stated that Resident #3's PASARR status was negative from the hospital. She stated she was working on a 1012 form for him, which would be a change to his PASARR status. MDS A stated that the resident's PASARR should have been positive since Resident #3 had a current diagnosis of major depressive disorder. She stated the level 1 PASARR would be deemed inaccurate. MDS A stated that Resident #6's PASARR status was negative and she would complete a form 1012 on her as well. She stated if they completed a 1012 on the resident, then had a diagnosis later, it would not change the PASARR status due to her having a primary diagnosis of dementia at that time. She stated she was not sure if the primary diagnosis was no longer dementia, if a new PASARR should have been completed.An interview on 04/29/2026 at 12:54PM was conducted with RVP who stated the policy for PASARR was to follow guidelines for CMS or HHSC. RVP did not elaborate what those guidelines were. RVP stated that depending on the admission, they would follow the protocol regarding PASARR and upon a change of a diagnosis. RVP stated that nurse management would have been responsible for ensuring that the PASARR was accurate. RVP stated that she was not sure which diagnosis would indicate a positive PASARR 1. RVP stated that if the level 1 was positive, they would then put a PE in place and notify the local authority. She stated an inaccurate level 1 PASARR could delay the evaluation from the local authority. RVP stated she did not know the status of Resident #3's PASARR status. She stated that to her knowledge a diagnosis of major depressive disorder would not indicate a positive PASARR. She stated if that were a diagnosis for PASARR then it would be inaccurate level 1. RVP stated she did not know the status of Resident #6's PASARR. Status. She stated that to her knowledge a diagnosis of bipolar disorder would indicate a positive PASARR. She stated that if Resident #6's diagnosis came after her level 1 PASARR was completed, then a new PASARR should have been generated. She stated that a delay in services could be the result of not having the PASARR regenerated.An interview on 04/29/2026 at 1:30PM was conducted with the DON who had been employed at the facility for 12 years. The DON stated that he did not know the policy on PASARR. The DON stated PASARR's should be completed upon admission. He stated that the MDS takes care of PASARR responsibilities. He stated he did not know which diagnoses would indicate a positive PASARR 1. The DON stated if a resident had an inaccurate PASARR the benefits residents may have been eligible for could be missed. The DON stated he did not know Resident #3's or Resident #6's PASARR status. The DON stated if a resident had a diagnosis of bipolar disorder, to his knowledge the PASARR should have been positive. The DON stated that if a resident's diagnosis changed after the level 1 PASARR was completed, a new PASARR should have been generated.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals for 1 of 3 residents (Resident #32) reviewed for pharmacy services. The facility failed to ensure CMA C administered a correct dose of Cholecalciferol Oral Tablet 10 MCG to Resident #32 for a week without obtaining a correct doze of medication according to the physician order. This failure could place residents at risk for overdosing, delayed healing, and other adverse consequences. Findings included: Record review of Resident # 32's face sheet, dated 04/28/2026, reflected [AGE] year-old male admitted on [DATE] with diagnoses that included: hypothyroidism (a condition where the thyroid gland fails to produce enough hormones, causing bodily functions to slow down), severe protein-calorie malnutrition (a critical condition resulting from extreme deficiencies in energy and protein intake, leading to severe metabolic imbalances, muscle wasting, and loss of subcutaneous fat), chronic obstructive pulmonary disease (a progressive lung disease that causes severe breathing difficulties), and chronic kidney disease (the long-term, progressive loss of kidney function, often causing waste to build up in the body). Record review of Resident #32's medication administration record for April 2026 revealed medication administration of Cholecalciferol Oral Tablet (vitamin D3 supplements) 10 MCG (400 Unit) Give 1 tablet by mouth one time a day for Supplement with start date 04/19/2026 and administered to Resident #32 every day from 04/19/26 - 04/27/26 for 9 days. Record review of Resident #32's Order Summary Report, dated 04/28/2026, revealed an order for Cholecalciferol Oral Tablet 10 MCG (400 Unit) Give 1 tablet by mouth one time a day for vitamin D supplement with start date 04/19/2026. During an observation of Resident #32's medication administration and interview on 04/28/2026 at 9:16 a.m., CMA C removed an over-the-counter container of Cholecalciferol Oral Tablet 50 MCG (2000 UT) and attempted to split a pill before putting in a medication cup with other medications for Resident #32. CMA C stated that it's the wrong doze, but they don't have the correct doze on the cart or medication storage, so she splits the tablet in quarters and administers to Resident #32 a quarter of the tablet. CMA C stated that the tabled was not scored and she approximated when she split a pill. CMA C stated that 50 MCG could not be split evenly to get a correct doze of 10MCG. She stated that she reported this discrepancy to a charge nurse whose name she could not remember for sure, but the charge nurse got busy and did not order the correct doze of medication (Cholecalciferol Oral Tablet 10 MCG). CMA C stated that usually DON ordered over-the-counter medications. She stated that she had training on mediation administration with verification of correct doze of each medication. She stated that not administering the correct dose could lead to a medication error and potentially resident's overdosing on medication. CMA C stated that she administered wrong doze of this medication for a week. She stated that she should document this discrepancy in resident's medication records and not administer the wrong doze of medication. During an observation and interview of Resident #32 on 04/28/2026 at 9:45 a.m., he stated that he did not know about wrong doze administered to him and did not feel any adverse effects of it. No adverse effects of D3 toxicity like upset stomach, vomiting, weakness, and frequent urination were observed at that time. During an interview on 04/28/2026 at 9:31 a.m., ADON stated that charge nurses and CMAs were responsible for following 5 rights of medication, including correct doze of medication, according to the physician order on MAR. She stated that if correct doze of medication was not available in the facility, charge nurses or CMAs were responsible to notify ADON or DON and they would contact physician to change the order. She stated that incorrect doze should not be administered or a pill split to get a correct doze which could lead to a medication error and adverse reaction to residents' health. She stated that if correct doze of medication was not available, it should not be administered while obtaining a correct doze or changing the order. ADON stated that medication errors should be reported to the physician and documented in Resident #32's progress notes. She stated that it was not done and she would immediately correct it. During an interview on 4/28/2026 at 9:45 a.m., DON stated that he was not informed of incorrect doze administered to Resident #32 before today. He stated that he was responsible for ordering over-the-counter medications in the facility. DON stated that charge nurses and CMA were responsible for administering correct medication dosages and holding medications if correct doze was not available in the building. He stated that per policy charge nurses and CMAs were responsible for documenting medication errors including wrong doze of medication administered to residents. He stated that medication errors should be communicated to him, ADON, physician and resident's representative. DON stated that the potential risk for administering wrong doze of medication would be overdosing and medication errors. Review of facility in service titled CMA C orientation/competency checklist, dated 1/20/26, reflected: 5 Rights when administering medication. Accurate measuring/dozing signed by CMA C. Review of facility policy titled Administering Medication, dated April 2019, reflected: Medications are administered in accordance with prescriber order,. 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: b. the dosage.

Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure Dietary Aide A and Dietary Aide B's hair was completely contained with an effective hair restraint. This failure could place residents at risk of being served unsanitary food and foodborne illness. Findings Included: During an observation in the Kitchen on 02/17/25 at 7:35 a.m., Dietary Aide B had approximately 3-4 inches of hair in the nape (back of her head) and wisps of her hair (around front profile of face) not covered with hair net. She was standing at the prep table preparing drinks (milk, juice). During an observation and interview on 02/17/25 at 7:45 a.m., Dietary Aide B had approximately 3-4 inches of hair on the back of her head and wisps of her hair around her face not covered with a hair net. Dietary Aide B said she Believe she was told to cover whole head with a hair net because hair could get in the food during her training. Dietary Aide B continued to prepare drinks. During an observation and interview on 02/17/2025 at 11:30 a.m., Dietary Aide A walked in the kitchen to the Manager's office passing in front of food being plated by the [NAME] without wearing a hair net. Dietary Aide A said she had only worked at the facility for one month and had been trained to wear a hair net in the kitchen area. Dietary Aide A said she did not have a hair net on because she was just passing by the food on the steamtable. Dietary Aide A said not wearing a hair net could allow hair to get in the food. During an observation on 02/17/2025 at 12:00 p.m., Dietary Aide B had approximately 3-4 inches of hair on the back of her head and wisps of her hair around her face not covered with a hair net. Dietary Aide B was standing in front of food that had been plated by the [NAME] and placed on the prep table for lunch. Dietary Aide B picked up the plate, shook parmesan cheese on the spaghetti, covered it with a lid, placed it on the tray and handed it to a server in the dining room. During an interview on 02/17/2025 at 1:00 p.m., the Dietary Manager stated all staff's hair were to be covered with a hair net when entering the kitchen. She stated she would make sure Dietary Aide B covered her hair completely with no hair hanging in the back or sides of her face and Dietary Aide A was not on duty when she entered the kitchen from the dining room. She stated everyone who entered the kitchen from any door was required to wear a hair net and there were no exceptions. During an interview on 02/19/2025 at 8:30 a.m., the Administrator stated if any staff entered the kitchen, they were expected to wear a hair net. He also stated if a staff's hair was not completely covered, the risk would be food getting in the resident's food, and he had no complaints of food. Record review of facility undated policy titled Dietary and Food Service indicated, Policy: Hair Nets Procedure: It is MANDATORY that All Dietary Staff wear hairnets while on duty in any food preparation area in this facility .

Based on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 16 residents (Resident #34) reviewed for accidents and supervision. The facility failed to ensure that Resident #34 did not have cigarettes and a lighter in her purse and in her room. This failure could place residents at risk for injury, harm, and impairment. Findings included: Record review of the face sheet dated 02/17/25 indicated Resident #34 was [AGE] years old and was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and high blood pressure. Record review of a significant change MDS assessment dated [DATE] indicated Resident #34 was able to understand and was understood. The MDS indicated a BIMS score of 13 indicating Resident #34 was cognitively intact. The MDS indicated Resident #34 required use a walker to ambulate and supervision for some ADLs. Record review of the safe smoking assessment dated [DATE] indicated Resident #34 was able to lift cigarettes to her mouth without assistance. She was able to light her own cigarettes. Resident #34 went outside with her family to smoke. Record review of Resident 34's care plan was initiated on 01/09/25 indicated a focus area was the resident smoked. They were advised of the facility smoking policy. The resident required supervision with smoking. Resident #34 smoked outside with family during visits. The interventions indicated to remind the resident and family that all cigarettes, lighters, matches and smoking paraphernalia must be kept at nursing station, and to remind the resident and family that staff supervision would be provided when not interfering with care. During an interview on 02/17/25 at 11:45 a.m. Resident #34 said she smoked with her family outside. During an observation and interview on 02/17/25 at 11:50 a.m., Resident #34 said she had her cigarettes and lighter in her purse and pulled them out of her purse. She asked, Am I breaking the rules? She put the cigarettes and the lighter back into her purse. During an interview on 02/17/25 at 11:55 a.m., the DON said all cigarettes and lighters were kept with the family. He said we do not have a lock box at the nurse's station. The DON said the smoking policy indicated the family was to keep the lighter and cigarettes. During an interview on 02/17/25 at 12:15 a.m., the Administrator said if residents kept the cigarettes and lighters there could be a potential for accidents. He said he was not aware Resident #34 had a lighter and cigarettes in her purse. He said the policy indicated the cigarettes and lighters would be kept with the resident's family. He said the policy was included in the admission packet. The Administrator said the facility did not offer supervised smoking times. He said the family were responsible for bringing cigarettes and allowing their residents to smoke outside during the family visits. Record review of resident smoking-prohibited indicated This facility does not allow smoking by the residents at any time during ones stay. If a resident is found to be smoking or be in possession of any kind related paraphernalia only one warning will be provided .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents. (Resident #34) The facility failed to develop an accurate care plan for Resident #34 smoking and renal disease. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being. Findings included: Record review of the face sheet dated 02/17/25 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and high blood pressure. Record review of the physician orders dated February 2025 indicated Resident #34 did not have orders to be sent for dialysis (a medical treatment that removes waste and excess fluid when the kidneys are not functioning properly) treatments. Record review of a significant change MDS assessment dated [DATE] indicated Resident #34 was able to understand and was understood. The MDS indicated a BIMS score of 13 indicating Resident #34 was cognitively intact. Resident #34 required a walker to ambulate and supervision for some ADLs. Dialysis was not checked on the form which would have indicated dialysis was being received on admission or during last 14 days. Record review of Resident #34's care plan initiated on 05/03/24 indicated Resident #34 had a diagnosis of renal disease. The resident was at risk for complications related to having a shunt (an artificial passageway allows blood to flow to another area). The interventions included checking the shunt access site dressing after dialysis for uncontrolled bleeding, redness, swelling, and for decreased bruit at the shunt site, notifying the physician of abnormal findings, and to encourage and allow the resident to rest as needed post dialysis, ensure the resident was ready for dialysis on (day), (day), (day), and to remind dietary of need for a to go meal to take with them to dialysis. Record review of Resident #34's care plan was initiated on 01/09/25 indicated the resident smoked cigarettes. The interventions indicated to remind the resident and family that all cigarettes, lighters, matches and smoking paraphernalia must be kept at the nursing station. Remind the resident and family that staff supervision would be provided when not interfering with her care or other residents' care. During an interview and observation on 02/17/25 at 11:45 a.m., Resident #34 said she did not go to dialysis. She pulled her arms out of the covers and said she had no shunts or grafts. During an observation and interview on 02/17/25 at 11:50 a.m., Resident #34 said she had her cigarettes and lighter in her purse and pulled them out of her purse. She asked, Am I breaking the rules? She put the cigarettes and the lighter back into her purse. During an interview on 02/17/25 at 11:55 a.m., the DON said all cigarettes and lighters were kept with the family. During an observation on 02/17/25 at 1:00 p.m., Resident #34 was outside with her family smoking and the family was keeping the cigarettes in his pocket and the lighter was kept by the family. Resident #34 was able to hold her cigarette and did not drop ashes or the cigarette on herself. During an interview on 02/18/25 at 10:54 a.m., the MDS nurse said she was responsible for care plans and MDS assessments. She said the intervention was incorrect on the smoking care plan. She said the interventions for dialysis might have been from 2019 when she was a resident here before. The MDS nurse said the risk of the interventions being incorrect was the resident might not get the proper care and services. She said the next full MDS assessment would include smoking because at the time of the last full assessment Resident #34 was not smoking. During an interview on 02/18/25 at 11:30 a.m. the DON said he wanted the care plans to be correct. He said if the care plans were incorrect the resident might not receive the needed services or might cause confusion. Record review of the undated Comprehensive Care Plans policy indicated Procedures: 1. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being. Procedure: After admission to the facility: 1. Nursing completes the Admission Assessment within 24 hours. 2. A Registered Nurse (RN) will review Admission Assessment for completion. 3. The RN will then initiate the Care Plan in PCC under the resident clinical chart. 4. Once initiated, the RN will View the Triggered Care Plan Items Now area of the Care Plan (Located in Edit Care Plan area top right corner of screen) 5. RN will review and select appropriate care plans for list or choose to Select All feature then Save Care Plan .

Based on interview and record review, the facility failed to inform the resident's family and responsible party when there was a change in resident condition for 1 (Resident #1) of 3 Residents reviewed for resident rights. The facility failed to inform Resident #1's family when Resident #1 developed pressure ulcer at her coccyx (commonly referred to as the tailbone, is the final segment of the vertebral column) area on 08/05/2024 and had to be seen by the Wound Care Doctor. This noncompliance was identified as PNC. The deficient practice began on 08/05/24 and ended on 08/26/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of their responsible party not being involved in their medical care and treatment. Findings included: Review of Resident #1's face sheet dated 09/12/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified fracture of right femur (the longest bone in the human body, it extends from the hip to the knee) , subsequent encounter for closed fracture with routine healing, essential tremor and presence of unspecified artificial knee. Face sheet also reflected Resident #1 had emergency contacts. Review of Resident #1's Nursing Home Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 00, staff assessment indicated both long- and short-term memory problems. The MDS also reflected Resident #1 was at risk for developing pressure ulcer. Review of Resident #1's care plan initiated 08/01/2024 reflected Resident #1 had a communication problem related to cognition, ability to voice wants and needs; resident had potential/actual impairment to skin integrity r/t fragile skin, surgical incision to hip. Review of Resident #1's skin reported dated 08/05/2024 reflected pressure area at her coccyx area. Review of Resident #1's progress notes from 08/05/2024 through 08/24/2024 reflected no area where Resident #'s family was notified of pressure ulcer development or consent from family for Resident #1 to be seen by the Wound Care Doctor. Review of Resident #1's wound doctor's notes reflected Resident #1 was seen by the wound care doctor on 08/15/2024 and 08/21/2024 for pressure ulcer to her coccyx area. Review of Resident #1's progress notes dated 08/24/2024 reflected Resident #1 was transferred to the local hospital. During an interview on 09/12/2024 at 2:16 pm LVN A stated she worked with Resident #1 on 08/05/2024 and that was the day the wound on Resident #1's buttocks was discovered. LVN A stated she was alerted by Resident #1's CNAs and she alerted the DON. LVN A stated she did not notify Resident #1's family because the DON took over the situation and she assumed the DON would have notified the family. LVN A stated after Resident #1 was transferred to the local hospital, the facility's administrator in-serviced staff on Resident's rights and notifying families and RPs of change of conditions. During an interview on 09/12/2024 at 3:16 pm, CNA B stated Resident #1 was admitted to the facility with a bruise at her coccyx area. CNA B stated when the area opened, she notified LVN A and LVN A went to assess Resident #1. CNA B stated she was not sure which date Resident #1's wound at her coccyx opened. During an interview on 09/12/2024 at 3:33 pm CNA C stated Resident #1 had a dark, bruise-like spot at her coccyx area and LVN A was notified when the area opened. CNA C stated she was not sure of the exact date Resident #1's wound at her coccyx opened . During an interview on 09/12/2024 at 3:53 pm the DON stated the first time he saw Resident #1's coccyx area was 08/05/2024 when the wound had opened. The DON stated he was called by LVN A, he went and assessed the wound. The DON stated he swore he called the family to notify them of the wound because he had to get consent for the Wound Doctor to treat the wound. The DON stated he did not document that he called the family or got consent for the Wound Care Doctor to treat. The DON stated if it is not documented, it is not done . The DON stated it was brought to their attention on 08/24/2024 that the family was not aware of Resident #1's pressure ulcer on the coccyx. The DON stated the Administrator conducted an in-serviced on Resident's Rights and family notification for all nurses. During an interview on 09/13/2024 at 10:31 am Resident #1's family stated they were not informed Resident #1 had developed a pressure ulcer. Resident #1's family stated they did not find out Resident # 1 had pressure ulcer until 08/24/2024 when she was being transferred to the local hospital . Resident #1's family stated they were told the wound started to develop on 08/05/2024. Resident #1's family also stated they did not know Resident #1 was being seen by the wound care doctor, they did not sign a consent. During an interview on 09/13/2024 at 1:24 pm the Administrator stated Resident #1's family had called to complain that they were not made aware by the facility that Resident #1 had a pressure ulcer at the coccyx area. The Administrator also stated during the same conversation that someone had called on 08/05/2024 to inform them. The Administrator stated he completed a grievance form, interview staff and conducted training in-serviced on Notification to Physician, family and others; a post test was completed along with the training. Review of facility's in-service dated 08/26/2024 reflected an in-serviced titled Notification to Physician, family and others and was signed by nurses. It was also reflected staff completed a post test. It was also reflected Post test addressed who, when and why notification are made. During an interview on 09/13/2024 at 4:00 pm LVN D stated she was in-serviced on family notification and residents' rights about 2 weeks ago. LVN D stated the family, and the physician should notify of any change in resident's condition like infection, skincare and/or anything that is not normal for the resident. During an interview on 09/13/2024 at 04:09 pm LVN E stated she was in-serviced recently on family notification. LVN E stated families and physician should be notify of falls, medication changes, skin discoloration, and any procedure that may come up for a resident. During an interview on 09/13/2024 at 04:06 pm LVN A stated she was in-serviced on family notification on change of condition. Review of facility's policy titled Resident's Rights undated reflected the following: Purpose .To ensure that resident rights are respected and protected. .To inform residents of their rights and provide an environment in which they can be exercised. To be informed of, and participate in, his or her treatment, including the right to: o Be fully informed in a language they can understand of their total health status o Be informed, in advance, of changes to the plan of care o Be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish the care o Be informed, in advance, by the physician of the risks and benefits of proposed care, of the treatment and alternatives and the right to choose the alternative option they prefer. Review of facility's policy titled Notification to Physician, Family and others undated reflected the following: The facility will remain compliant with reporting guidelines as outlined by state and federal regulations. Notifications of changes --- The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative and document in the resident's medical record where applicable, when there is: o A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); o A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment);

Based on interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to ensure Resident #1 had physician orders for her indwelling foley catheter (is a sterile tube that is inserted into your bladder to drain urine) or for care and monitoring. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain. Findings included: Review of Resident #1's face sheet dated 09/12/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified fracture of right femur (the longest bone in the human body, it extends from the hip to the knee) , subsequent encounter for closed fracture with routine healing, essential tremor and presence of unspecified artificial knee. Review of Resident #1's Nursing Home Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 00, staff assessment indicated both long- and short-term memory problems. Section H (Bladder and Bowel) reflected Resident # 1 had an indwelling catheter. Review of Resident #1's care plan initiated 08/01/2024 and revised 08/08/2024 reflected Resident #1 had an indwelling catheter and at risk for UTI/complications. Care plan interventions included -- assess reports of abnormal urine - sediment, odor, color, amount, etc. report to MD as needed. Empty and record output every shift and PRN, Observe for and document S/S of complications/UTI to include but not limited to: color, consistency, amount of urine, condition of skin at insertion site, pain, burning, discomfort, change in mental status and notify MD of findings, change foley tubing and bag as ordered, check tubing after providing care for kinks, tubing and bag below the level of the bladder reposition as needed, Catheter care per facility policy and PRN, change Foley Catheter every month and as needed. Review of Resident #1's Physician orders from 07/26/2024 through 08/24/2024 reflected no orders for Foley catheter, Foley catheter care, Foley catheter monitoring, Foley catheter output etc. Review of Resident #1's MARs and TARs from 07/26/2024 though 08/24/2024 reflected no evidence of Foley catheter care, Foley catheter monitoring, Foley catheter output etc. Review of Resident #1's progress notes reflected Resident #1 was transferred to the local hospital on 08/24/2024 due to Resident #1 running fever and BP low and family requested Resident #1 be sent to the hospital. During an interview on 09/12/2024 at 2:16 pm LVN A stated Resident #1 had foley catheter throughout her stay in the facility. LVN A stated the CNAs were responsible to provide catheter care, empty the foley catheter and notify the charge nurses of output. LVN A stated the charge nurses were responsible to document foley catheter output. LVN A stated the CNAs always give her Resident #1's Foley catheter output and she did not know where she documented it. During an interview on 09/12/2024 at 3:16 pm, CNA B stated Resident #1 had foley catheter throughout her stay in the facility. During an interview on 09/12/2024 at 3:33 pm CNA C stated Resident #1 had foley catheter throughout her stay in the facility. During an interview on 09/12/2024 at 3:53 pm the DON stated, she had a foley catheter, she came in with a foley catheter. I think it was discontinued at some point and reinserted. There should have been an order for catheter care, output, monitoring. We have to have some way of monitoring; it is high risk for infection. During an interview on 09/13/2024 at 10:31 am Resident #1's family stated Resident #1 had Foley catheter throughout her stay at the facility. Review of the facility's policy titled Catheter Care, indwelling Catheter undated reflected no policy or procedure related to the implementation of physician's orders with regard to the presence of a catheter. It reflected: Basic responsibility -Licensed Nurse, Certified nurse's aide. Purpose-to prevent infection, to reduce irritation. Assessment guidelines: may include, but not limited to: color, consistency, amount of urine, condition of skin at the site of insertion, pain, burning, discomfort Review of facility's Policy titled Physician orders undated reflected: Physician Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on observation, interview, and record review, the facility failed to conduct an initial comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #165) reviewed for resident assessments. The facility failed to ensure Resident #165's Admission MDS Assessment accurately reflected her receiving hospice services. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: Record review of Resident #165's face sheet, dated 01/18/24, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included, senile degeneration of the brain (losing the ability to remember, to communicate effectively, and to use reasoning skills to function in their daily lives), dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), hypertension (high blood pressure), and depression (feelings of severe despondency and dejection). Record review of Resident #165's Admission MDS assessment dated , 12/28/23, reflected a BIMs score was coded as 9 indicating Resident #165 was moderately cognitively impaired. Record review of section O - special treatments, procedures, and programs O0110. K1. Hospice care revealed Resident #165 was coded N/A and No for receiving hospice services. Record review of Resident #165's clinical physician orders dated on admission, reflected Resident #165 was admitted to the facility under the care of hospice services. Record review of Resident #165's care plan dated 01/08/24 reflected Resident/family had elected hospice care for senile degeneration of the brain. Resident was at risk of complications related to dying process (weight loss, skin breakdown, dehydration, placement of indwelling catheter, fecal impactions, or gradual or rapid loss of the ability to move.) Goals: Resident and family's wishes would be honored through next review date; Resident would be kept as comfortable as possible through next review date. Interventions: Coordinate care with Hospice team. Hospice team to visit and perform care per schedule; Encourage and provide assistance to turn and reposition q 2 hours in PRN comfort; If transferring resident notify receiving facility of election of hospice and code status; Notify Hospice of resident and family request for Clergy support/visit, questions about dying process; Notify MD, Hospice of S/S of infection, injury and implement appropriate interventions within code status, Observe for S/S of impending death to include but not limited to: change in mental status, non-responsive, change in breathing pattern, change in heart rate, cyanosis (the change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen bound to the hemoglobin in the red blood cells of the capillary bed), mottling to extremities , decreased bowel sounds, increased lung sounds; Notify Hospice, RP, MD of change. In an observation on 01/17/24 at 11:39 AM Resident #165 was lying in bed, moaning at times, unresponsive to verbal stimuli, not able to answer questions. Resident #165 appeared clean and showed no signs of pain or distress. Resident #165's family was at bedside. Resident #165 had blankets pulled to chest area with call light in reach. In an interview on 01/17/24 at 11:46 AM with Resident #165's FM she stated things had been ok with the care of Resident #165 and Resident #165 had been residing in the facility since December 21st. She stated she had no concerns with anything right now. She stated Resident #165 was on the downhill and nothing could be done. She stated Resident #165 was on Hospice care and she had no concerns with hospice. She stated Resident #165 recognized the hospice nurse when she came in. In an interview on 01/19/24 at 9:03 AM with the MDS nurse, she stated she was responsible for completing all MDS assessments. She stated Resident #165 was a new admission and Resident #165 admitted under hospice services. She stated that Resident #165's admission MDS assessment was miscoded and that she needed to correct it. She stated she had been trained on how to complete the MDS assessments and she did not believe there was any effects that could have been caused from the MDS assessment being coded incorrectly. She stated Resident #165 was private pay and if Resident #165 would have been on MCR or MCD, it may have affected Resident #165 or the facility differently in a financial way. In an interview on 01/19/24 at 9:37 AM with the ADM, he stated if a resident was on hospice services it should be coded as yes on the MDS assessment. He stated hospice not being coded on the MDS assessment would not affect the care provided for the residents. He stated he did not feel there would not be any issues if hospice was not coded on the MDS assessment. He stated he was made aware that Resident #165's MDS assessment was coded incorrectly, and they were going to perform an audit of all MDS's. He stated the MDS nurse was responsible for completing the MDS assessment and had been working in the facility for about two years. He stated the MDS nurse had been trained on how to complete an MDS properly and that the MDS nurse is an RN and should be ensuring the accuracy of the MDS assessments. In an interview on 01/19/24 at 11:08 AM with the DON, he stated the MDS nurse was responsible for completing MDS assessments and she had been trained on completing the MDS's correctly. He stated they had a corporate nurse that ensured the accuracy of the MDS assessments. He stated the MDS assessments should reflect if a resident was admitted on or was receiving hospice care. He stated if an MDS assessment was completed incorrectly, someone may not know if a resident was on hospice services. Record review of facility MDS 3.0 user's manual dated October 2023: CMS's RAI Version 3.0 Manual; page O-7, O01 10K1, Hospice care - Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for dietary services. 1.The facility failed to ensure expired meat and cheese were discarded appropriately. 2.The facility failed to ensure cheese in the kitchen was dated and labeled appropriately. These failures could place residents at risk for food contamination and food-borne illness. Findings include: During an observation on [DATE] at 12:15 PM in the walk-in refrigerator revealed, the following items: 1. One plastic bag contained a chunk of pork loin with open date of [DATE] and used by date of [DATE]. 2. One block of cream cheese with an open date of [DATE] and a used by date of [DATE]. 3. One block of cream cheese dated [DATE]. There was no 'Use by date documented. 4.One plastic bag contained cheese slices dated [DATE]. There was no Use by date documented. 5. One plastic bag contained shredded cheese dated [DATE]. There was no Use by documented. During an interview on [DATE] at 1:00 PM with the DM, she stated food items kept in a refrigerator should be consumed within 7 days once they were opened or removed from the freezer for thawing. She stated consumption of expired meat could cause food borne diseases. The DM stated storing food products in the appropriate storage area in a sealed packet with the name, open and used by dates on it was necessary to know whether they were usable or not. She stated outdated food could cross contaminate other food. She stated it was her responsibility to ensure all the food items in the kitchen were within the expiry date. During an interview on [DATE] at 1:30 PM with the ADM, he stated He stated improper food handling caused food borne diseases and the staff in the kitchen needed further training related to food storage and handling. Record review reflected there were no trainings on food storage and handling from [DATE]. Record review of the facility's, undated, policy titled, Food Cooks reflected: .Provide food that is free from contamination thus risking the health and wellbeing of the residents and staff. Comply with Department of Health Guidelines in the food service department. Procedure: All staff will be aware of proper food handling and storage procedures . Open packages of food are stored in closed containers with tight covers and dated as to when opened . All containers must be labeled with the contents and date food item was placed in storage. Previously cooked foods can be held in refrigeration of 41 degrees F [Fahrenheit] or lower for up to 7 days and then must be discarded .

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of five residents reviewed (Resident #1, #2, and #3) for respiratory care. 1. The facility failed to ensure Resident #1's humidifier for the oxygen concentrator had water. 2. The facility failed to ensure Resident #1's nebulizer mask was bagged while not in use. 3. The facility failed to ensure Resident #2's oxygen tubing was changed weekly as ordered. 4. The facility failed to ensure Resident #3 had an oxygen sign posted outside her bedroom. These deficient practices could place residents at risk for inadequate care and respiratory infection. Findings include: 1. Record review of Resident #1's face sheet, dated 11/17/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included presence of unspecified artificial knee joint, Osteoarthritis (tissues in the joint break down over time), Hypertension, Heart failure, Hyperlipidemia (high fat level in blood), Localized Edema, Abnormal weight loss, Atrial fibrillation (irregular heart rhythm), Anemia, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (problems that cause breathing difficulty), Dementia, Psychotic Disturbance, Mood disturbance and Anxiety. Record review of Resident #1's quarterly MDS assessment, dated 09/19/23, reflected a BIMS of 8, which indicated her cognition was moderately impaired. Section O (Special Treatments, Procedures, and Programs) reflected she received respiratory therapy 7 days a week. Record review of Resident #1's quarterly care plan, revised 09/20/23, reflected: Resident is at risk for shortness of breath, respiratory distress, increased anxiety due to Dx COPD. and the relevant interventions were: Provide O2 as ordered and indicated .Provide NEB/inhalers as ordered. Record review of Resident #1's physician order, dated 09/07/23, reflected: 1.O2 via Nasal Cannula: Titrate O2 2-5 LPM to keep SPO2 equal or greater than 92%. Write liters per min of O2 or Room Air. Check Q Shift. 2.Change out nebulizer mask and tubing weekly. Nursing to date and initial on plastic bag and equipment to be stored in bag when not in use. 3.Check face mask and tubing weekly. May replace if appears soiled or known contamination. Replace personal bag at bedside for items when not in use. Observation and interview on 11/17/23 at 10:00 AM revealed Resident #1 was laying in her bed. She was getting oxygen from the oxygen concentrator via tubing. The water bottle attached to the concentrator, dated 10/23/23, was empty. Resident #1 reported that it was for a while the staff had changed the tubing. She stated she did not remember the exact day when they changed the tubing. Observation on 11/17/23 at 10:05 AM revealed, on Resident #1's bed side table the nebulizer mask was placed unbagged, with the inside of the mask facing down. 2. Record review of Resident #2's face sheet, dated 11/17/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Hyperlipidemia, Osteoarthritis (tissues in the joint break down over time), Hypertension, Muscle wasting, Abnormalities of gait and mobility, Cognitive communication deficit, Dysphagia (Difficulty to swallow), Dementia, Behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety and Major depressive disorder. Record review of Resident #2's quarterly MDS assessment, dated 10/24/23, reflected the resident was unable to complete the interview. Section O (Special Treatments, Procedures, and Programs) reflected she was on oxygen therapy. Record review of Resident #2's quarterly care plan, revised 11/12/23, reflected: The resident has Oxygen Therapy r/t SOB. and the relevant intervention was: Oxygen settings: The resident has O2 via nasal prongs/mask @ 2L continuously. Record review of Resident #2's physician order, dated 09/07/23, reflected: 1. Change O2 tubing, humidifier bottle, and bag to place tubing in every Saturday night shift. If resident hasO2 tank on WC, place a separate bag on WC for NC. Cleanse concentrator filter. May replace as needed. 2. Titrate O2 to keep SPO2 greater than or equal to 90%. Check O2 sats every shift. Observation on 11/17/23 at 12:00 PM revealed Resident #2 was not in her room. The nasal cannula was connected to the oxygen concentrator and was dated 10/29/23. There was no humidifier attached to the tubing. The facility did not change the humidifier and oxygen tubing every Saturday as ordered by the physician 3. Record review of Resident #3's face sheet, dated 11/17/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Radiculopathy (pinched nerve), Edema (Swelling), Atrial Fibrillation (Irregular Heartbeat), Sciatica (pain, weakness, numbness, or tingling in the leg), Low back pain and Seasonal allergy. Record review of Resident #3's initial MDS assessment, dated 11/08/23, reflected her BIMS score was 13, which indicated she was cognitively intact. Section O (Special Treatments, Procedures, and Programs) reflected she was on oxygen therapy. Record review of Resident #3's initial care plan, dated 11/12/23, reflected: The resident has Oxygen Therapy r/t SOB. and there were no interventions listed. Record review of Resident #3's physician order, dated 11/02/23, reflected: 1. O2 via Nasal Cannula: Titrate O2 2-5LPM to keep SPO2 equal or greater than 90%. Write liters per min of O2 or Room Air. Check Q Shift. 2. Check O2 tubing, humidifier water, and filter weekly on night shift. May replace if appears soiled or known contamination. Cleanse concentrator filter. Replace personal bag at bedside for items when not in use. If resident has O2 tank on walker, Place separate bag on WC for items. Observation on 11/17/23 at 12:00 PM revealed Resident #3 was in her room in a wheelchair. There was no sign posted outside her bedroom which stated she was on oxygen usage. During an interview on 10/17/23 at 1:47 PM, the DON stated his expectations were that oxygen tubing, mask and humidifier were replaced weekly though the policy stated change them when contaminated or visibly soiled. He stated the nurses were responsible for ensuring the tubing was changed weekly. The DON said the importance of changing the oxygen tubing regularly was to ensure the tubing was providing adequate oxygen, there were no kinks in the tubing, and to prevent respiratory infections through contamination. The DON stated the risk of not having the oxygen sign posted was the risk of fire due to the high flammability of oxygen and everyone was responsible for ensuring the oxygen signs were posted. Record review of the facility's, undated, policy Oxygen Administration reflected: .5. Prefilled, scaled, disposable humidifiers may be changed per facility procedure. . 8. precaution: constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulceration. 9. Check and clean oxygen equipment (including filter), masks, tubing and cannula, if visibly spiled or otherwise known to be contaminated, replace masks, tubing and/or cannula. Regular replacement intervals are not required, but nor otherwise prohibited.

Based on interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of 5 (Resident #1) residents reviewed for pressure ulcers. The facility failed to ensure Resident # 1, who transferred from another facility with a pre-existing pressure ulcer, received an initial assessment and a 48-hour initial care plan. The facility failed to ensure Resident #1 received an order for the treatment of a pre-existing pressure ulcers upon admission. The facility failed to ensure Resident #1's pressure ulcer was measured at the initial skin assessment. The facility failed, for the first 4 days of Resident #1's admission at the facility, to administer treatment for her pressure ulcer. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #1's Face Sheet dated 10/23/23 reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses type 2 diabetes mellitus with foot ulcer and acute systolic (congestive) heart failure. Review of Resident #1's initial MDS dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 12 indicating moderate cognitive impairment. Resident #1 entered the facility from another nursing home. Resident #1 had an active diagnosis of medically complex conditions. Resident #1 was a tobacco user. Resident #1 had an infection of the foot, a diabetic foot ulcer. Review of Resident #1's Comprehensive Care Plan reflected a focus area initiated on 10/11/2023 - Resident #1 has a diabetic Ulcer related to diabetes, poor circulation, non-compliance with diabetic diet. Resident #1 had Care Plan intervention/tasks initiated 10/11/2023 listing - 1. Carefully dry between toes but do not apply lotion between toes. 2. Determine and treat cause: Poor fitting shoes, blood sugar control, pressure area, infection. 3. Ensure appropriate protective devices are applied to affected areas. 4. Monitor pressure areas for color, sensation, temperature. 5. Monitor/document wound size, depth, margins: document progress and wound healing on an ongoing basis. Notify MD as indicated. 6. Monitor/document/report to MD signs and symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever. 7. Monitor/document/report to MD as needed changes in wound color, temp, sensation, pain, or presence of drainage or odor. 8. Petal space pulses with leg and foot ulcers. 9. Physician resident of affected area. Change position every two hours and PRN. 10. Refer to foot care nurse/podiatrist. 11. Treat wounds as per facility protocol. Review of Resident #1's previous facility orders dated 08/30/23 reflected order to cleanse open area to L heel and apply calcium alginate (calcium alginate used for entrapment of enzymes and forming artificial seeds in plant tissue culture) to wound bed and cover with dry protective dressing each day shift. Review of Resident #1's Admission Skin assessment dated [DATE] reflected pressure ulcer on L heel no length, width, depth, or stage documented . Review of Resident #1's facility order audit report dated 10/23/23 reflected on 09/24/23 an order was placed for wound care: apply Calcium Alginate (calcium alginate used for entrapment of enzymes and forming artificial seeds in plant tissue culture) to wound bed, cover with heel cup and wrap with stretch gauze. Skin prep entire heal everyday shift for weight loss for 30 days. Review of Resident #1's MAR reflected wound care treatment for order began on 09/25/23. Interview with the DON 10/23/23 at 2:44 pm, revealed he was responsible for resident initial care plan or 48-hour care plan prepared for Resident #1. The DON revealed he just forgot to do it. He revealed it is important to do a resident care plan to make sure that all staff members know what is needed for the resident and for the residents to get the care they need. The DON revealed that it is the facility's policy to conduct an initial resident assessment and baseline care plan within 48 hours of the resident entering the facility. The DON was unaware that Resident #1 did not receive an order for treatment for her pressure ulcer until 3 days after her admission to the facility and treatment did not begin until 4 days after her admission to the facility. The DON revealed that if pressure ulcers are not care planned and go untreated, they could get worse, become infected, could become septic and the resident could be in pain. Interview on 10/23/23 with the ADON at 2:33 pm, revealed that it is facility policy that residents receive a skin assessment within 24 hours of entering the facility and the type of dimension, and stage of the pressure is documented. She revealed that if pressure ulcers are not treated, they could become septic and there is a danger of death. Interview on 10/23/23 with the wound care doctor at 3:01 pm, revealed the first time saw Resident #1 for wound care was on 09/26/23 and that her pressure ulcer was present prior to Resident #1's admission to the facility. The wound care doctor revealed Resident #1 was a high risk for pressure ulcers complications because she had diabetes and was a smoker. The wound care doctor revealed that these are the 2 highest risk factors involving pressure ulcer condition. He revealed it is important for the facility to assess residents upon admission because it is important to know what type of wound you are handling. Non treatment of a pressure ulcer with a diabetic resident condition could cause the wound to worsen and get infected could lead the overall progression of the disease . Interview on 10/23/23 with the ADM at 3:34 pm, revealed it was the policy of the facility that a in initial assessment upon admission and baseline care plan and skin assessment be performed on every resident within 48 hours of the resident's admission into the facility. Review of facility skin assessment policy undated reflected the facility is to provide a routine schedule of assessments for each resident skin assessment and ensure prompt identification and treatment for noted skin concerns. Assess the resident head to toe to identify all skin concerns to include but not limited to pressure ulcers of any type. For new skin concerns or worsening conditions notify the director of nurses, medical doctor, and family of any new skin concerns to include pressure ulcers. Implement appropriate treatments, interventions protocols or obtained appropriate treatment orders. Review of facility at baseline care plan policy undated revealed objectives: to ensure uniformity of concern approached by nursing home and team members. To help resident and their families be part of a team approach in ensuring residents needs and assessing with problems period to clearly delineate instructions and needed to provide effective and in person centered care of their resident that meet professional standards of quality care. Review of facility baseline care plan undated revealed nursing home staff will develop a baseline care plan for the resident's care within 48 hours of admission to the facility. The baseline care plan will include, at minimum, the following: initial goals based on admission orders and physician orders. Review of facility Preventing Pressure Ulcers Repositioning to Prevent and Treat Heel Pressure Ulcers policy undated revealed: inspect the heels at least daily.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen where all facility food was prepared. The facility failed to ensure the expired ground meat in the refrigerator in the kitchen was discarded appropriately. The facility failed to ensure the dented food can in the dry storage in the kitchen was discarded appropriately The facility failed to ensure the hotdog buns in the kitchen were dated, labeled, sealed, and stored appropriately. These failures could place residents at risk for food contamination and food-borne illness. Findings included: During an observation on [DATE] at 11:15 am in the kitchen the following items were found: 1.One packet of ground beef weighing 5 pounds at the bottom shelf of the refrigerator. The meat was very soft to touch and slightly dark in color. The date of removal from the freezer written on it was [DATE]. 2.One can of 'sloppy [NAME] sauce' weighing 6 pounds with a dent measuring 1.5-inch D x 2-inch W x 3- inch L, stored in the dry storage area. 3.One plastic bag containing 8 hotdog buns on the countertop at the back of the kitchen among various utensils and containers. The bag was not sealed and dated. During an interview on [DATE] at 11.30am with DMC, she stated she was the cook and in charge of the kitchen activities that day in the absence of DM. She stated the ground meat should not have been there or in the refrigerator as it was old for consumption. When the investigator asked what the facility policy about meat products, DMC said she was not sure about the facility policy however knew that meat kept in a refrigerator should be consumed within 7 days once it was removed from the freezer for thawing. She stated consumption of expired meat could cause food borne diseases. DMC stated food products in dented cans should not be used for cooking. When the investigator asked what the consequence was of using food item in dented cans, DMC said she did not know the reason. DMC stated storing food products in the appropriate storage area in a sealed packet with name and date on it was necessary to know whether they were usable or not. During an interview on [DATE] at 11.45am when the investigator asked DA A why the food items in a dent can should not be used, DA A stated she did not know the reason however knew dented cans should be returned to the supplier. When investigator asked what the shelf life of meat in a refrigerator after removed from a freezer for thawing, DA A stated she did not know. DA A stated all the food items stored should be labeled and sealed properly. During an interview on [DATE] at 1:30pm with ADM stated it was unfortunate that there were deficiencies in food handling in the kitchen. He stated improper food handling causes food borne diseases and the staff in the kitchen needed further training related to food storage and handling. Record review on [DATE] reflected there were no training on food storage and handling in the last three months. Record review on [DATE] of the facility policy titled, Food Cooks Senior Care LLC not dated reflected: .Provide food that is free from contamination thus risking the health and wellbeing of the residents and staff. Comply with Department of Health Guidelines in the food service department. Procedure: All staff will be aware of proper food handling and storage procedures . . Food will be served in such a way as to prevent growth of bacteria . . Open packages of food are stored in closed containers with tight covers and dated as to when opened . . All containers must be labeled with the contents and date food item was placed in storage. Previously cooked foods can be held in refrigeration of 41 degrees F [Fahrenheit] or lower for up to 7 days and then must be discarded . Record review on [DATE] of U.S. Department of Agriculture website https://ask.usda.gov/s/article/Is-it-safe-to-use-food-from-dented-cans dated [DATE] reflected: If a can containing food has small dent but is otherwise in good shape, the food should be safe to eat. Discard deeply dented cans. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with deep dent on any seam.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 5 (Resident #27, Resident #34, Resident #36, Resident #44, Resident #54) of 6 residents reviewed for care plans. 1. The facility failed to develop a care plan with use and warnings of anti-anxiety and depression medications for Resident #27 and Resident #54. 2. The facility failed to develop a care plan that properly identified Resident #34 and Resident #54's advance directives. 3. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #36, and Resident #54's hospice services. 4. The facility failed to update Resident #54's care plan to address changes in diet texture. 5. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #54's use and warnings of narcotics. 6. The facility failed to develop a care plan with measurable objectives and timeframes for Resident #44. These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: 1.Review of Resident #27's face sheet, dated 10/27/22, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Major depressive disorder, anxiety disorder, Alzheimer's disease, Review of Resident #27's MDS assessment, dated 09/09/22, revealed her BIMS was 3 (severe cognitive impairment). Her active diagnoses included: Alzheimer's Disease, anxiety, and depression. Review of Resident #27's Orders Summary Report dated 10/27/22, revealed the following orders: -Escitalopram Ozalate Tablet 5MG, Give 1 tablet by mouth one time a day for depression, dated 12/23/21, by prescriber. -Alprazolam Tablet 0.5 MG, Give 1 tablet by mouth three times a day for anxiety, dated 06/28/22, by prescriber. -Side Effects to antianxiety medication, monitor day and night shift, dated 08/02/22, by prescriber. -Side effects to antidepressant medications, monitor day and night shift, dated 08/02/22, by prescriber. Review of Resident #27's care plan dated 09/06/22, did not reflect Resident #27's use of anti-depression or anxiety medication or monitoring for side effects. 2.Review of Resident #34's face sheet, dated 10/27/22, revealed, he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: encephalopathy (disease of the brain), cerebral infarction (stroke), depression, and seizures. Review of Resident #34's MDS assessment, dated 08/22/22, revealed, his BIMS was 4 (severe cognitive impairment). His active diagnoses included: Cerebrovascular accident (stroke), seizure disorder, malnutrition, encephalopathy (disease of the brain), and depression. Review of Resident #34's Orders Summary Report, dated 10/27/22, did not reveal advance directive orders. Review of Resident #34's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form, dated and signed by responsible party on 09/27/21, revealed Resident #34's advance directive wish was do not resuscitate. Review of Resident #34's care plan, dated 08/17/22, reflected Resident #34's advance directive of Full Code initiated on 04/20/21. 3.Review of Resident #36's face sheet dated 10/27/22, revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: cerebrovascular disease (condition that affected blood flow and vessels in the brain), adult failure to thrive, depression, anxiety, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident #36's MDS assessment. dated 09/12/22, revealed his BIMS was 3 (severe cognitive impairment). His active diagnoses: Hypertension (high blood pressure), hyperlipidemia (high cholesterol), malnutrition, anxiety disorder, depression, and cerebrovascular disease. His active special treatment: Hospice care. Review of Resident #36's Order Summary Report dated 10/27/22, revealed the following orders: -Admit to Oaks Nursing Care (ONC) under the care of [Hospice Company], dated 09/03/22, by prescriber. -DNR, dated 09/03/22, by prescriber. Review of Resident #36's care plan dated 09/26/22, revealed no focus area, goal, or interventions for hospice care. 4.Review of Resident #44's face sheet, dated 10/27/22, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: nontraumatic intracerebral hemorrhage in hemisphere, subcortical (stroke), chronic obstructive pulmonary disease (lung disorder), hyperlipidemia (high cholesterol), and Type 2 diabetes mellitus with other diabetic neurological complications. Review of Resident #44's MDS assessment, dated 10/03/22, revealed his BIMS was 15 (cognitively intact). His active diagnoses included: diabetes mellitus, hyperlipidemia (high cholesterol), cerebrovascular accident (stroke), malnutrition, and chronic obstructive pulmonary disease. Review of Resident #44's clinical record revealed no evidence of a care plan completed. 5.Review of Resident #54's face sheet, dated 10/27/22, revealed he was an [AGE] year-old male who was originally admitted to the facility on [DATE]. His diagnoses included: pneumonia, weakness, hypertension (high blood pressure), anxiety, hypokalemia (low potassium level), and acute respiratory failure. Review of Resident #54's MDS assessment, dated 10/03/22, revealed his BIMS was 10 (moderate cognitive impairment). His active diagnoses included: hypertension (high blood pressure), malnutrition, anxiety, respiratory failure, hypokalemia (low potassium level), weakness. His active special treatment: Hospice care. Review of Resident #54's Order Summary Report dated 10/27/22, revealed the following orders: -Regular Diet: Mechanical soft texture, honey consistency, for swallowing issues, dated 10/14/22, by prescriber (verbal). -DNR, dated 10/03/22, by prescriber (written). -Morphine Sulfate (concentrate) solution 20 MG/ML, give 0.25 ml by mouth every 2 hours as needed for pain; shortness of breath, wheezing, dated 09/30/22, by prescriber (written). -Lorazepam Tablet 1 MG, Give 1 tablet by mouth every 4 hours as needed for anxiety or agitation. -Norco Tablet 5-325 MG (Hydrocodone-acetaminophen) Give 2 tablets by mouth every 6 hours as needed for pain, not to exceed 3 Grams of Acetaminophen in 24 hours. Resident #54's Order Summary Report did not have hospice services identified. Review of Resident #54's written orders in electronic health record system revealed a scanned copy of an order stated: Admit [Resident #54] to [hospice company], dated 09/28/22. Review of Resident #54's care plan, dated 09/28/22, revealed the following: - Focus: At risk for/history of weight changes and malnutrition to: protein calorie malnutrition, dated initiated: 07/28/22. - Intervention: Regular Diet, Mechanical soft texture, thin liquids dated 08/03/22. Resident #54's care plan inaccurately identified advance directive of Full Code dated 07/28/22 as there was an active DNR order dated 10/03/22. Resident #54's care plan did not have a focus, goal, or intervention/tasks for hospice services, narcotic medication, or anxiety medications. An interview on 10/27/22 at 12:49 PM with the DON revealed he worked for the facility since 2014. The DON stated initially the care plans were the responsibility of the MDS Coordinator. However, the facility had been without an MDS Coordinator for about a month. The DON stated the Director of Clinical Reimbursement (DCR/Corporate) was coming two times a week to ensure MDS assessments and care plans were maintained. The DON stated, during the time of not having an MDS nurse, he or the DCR were responsible for care plans. The DON stated if a resident went on hospice, he would create the referral and then when the family or resident agreed to hospice services, the hospice company provided him the paperwork and it was his responsibility to put the order into the system and update the care plan. The DON stated if the information was not in the care plan or electronic orders, the nurses could refer back to a paper chart. However, the DON reviewed Resident #54's paper chart, and there was no order present. The DON stated he was not sure what happened, but it appeared this slipped through the cracks. The DON stated the risk of not showing hospice orders, or any other individualized area, the nurses would not know the residents were on hospice, or who to notify or how to properly care for the residents. The DON stated a resident's diet, use of narcotics, anti-anxiety or depression medications, should be in the care plan. The DON stated again the risk of not having these areas on the care plan puts the residents at risk for not getting the services they deserve. The DON stated no one ultimately reviewed his work, he was trusted to input information accurately. An interview on 10/27/22 at 2:04 PM with the Administrator revealed he worked at the facility since August 2022. The Administrator stated he did not attend care plan meetings as a rule, but if there was a particular concern or need, he would be in attendance. The Administrator stated he did not input care plans. He relied on the DON and/or MDS Coordinator to input and update care plans as needed. The Administrator stated their past MDS Coordinator went back to being a floor nurse about a month ago as she was burnt out from completing MDS assessments and the lack of attention to detail was observed. The Administrator stated while they did not have an MDS Coordinator the facility relied on the Director of Clinical Reimbursement (DCR) and the DON to update and input care plans. The Administrator stated it was important to have accurate, individualized care plans for the residents because it tells the story of the resident. The Administrator stated if the care plans were not accurate, the resident was at risk for not receiving the individualized care they deserve. The Administrator stated, previously he knew there was an issue regarding accurate care plans, but thought the facility had resolved this deficiency. The Administrator stated he ultimately was responsible for all things in the building but to ensure the accuracy of care plans would fall on his DON. An interview on 10/27/22 at 2:23 PM with MDS Coordinator, revealed she was an RN and worked for the facility as a floor nurse since 2016; however, she was not hired for this position until 10/06/22, and she was still learning her position as she has never input an MDS. MDS C stated she could not speak to the accuracy of care plans prior to this date but would recommend the surveyors contact the DCR as she was training her for this position and completed care plans during the time of not having an MDS Coordinator. An interview on 10/27/22 at 2:25 PM with the DCR revealed she was an LVN and worked for the facility for over [AGE] years and was promoted to Director of Clinical Reimbursement about 1.5 years ago. The DCR stated she filled in as the MDS C at the facility from the first part of September until the new MDS C was hired on 10/06/222. The DCR stated she was still very involved in care plans and MDS assessments as the new MDS Coordinator had no experience. The DCR stated she would physically be at the facility two times a week for resident/family interviews and would continue to work on the care plans and MDS when she was not assisting her other facilities. The DCR stated when she began reviewing the care plans in September she saw a deficiency and she continued to try to get the care plans caught up. The DCR stated care plans should include all areas listed in the MDS to include, hospice, diet, ultimately anything that required a physician's order. The DCR stated care plans were important because that was how the staff knew how to care for the residents. The DCR stated if the care plans were not accurate the staff could not meet the needs of the residents appropriately or in a timely manner. Review of facility policy titled: Comprehensive Care Plans, undated, revealed the following: 1. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being, b. Any services that would otherwise be required but are not provided due to a resident exercising their right to refuse treatment and services . 3. The comprehensive care plan will be: a. Developed within 7 days after completion of the comprehensive assessment unless the comprehensive care plan will be used as the baseline care plan which requires completion within 48 hours of admission to the facility (See Baseline Care Plan Policy) .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 4 residents (Residents #3 and #18) reviewed for care plan updates in that Resident #3's care plan was not updated related to changes in diet texture and indicated behaviors that are no longer applicable. Resident #18's care plan did not address medications, changes in behaviors, and transfers via mechanical lift. This deficient practice could place residents at risk for inadequate care and treatment. The findings were: Review of Resident #3's Face Sheet, dated 09/09/21, reflected she was an [AGE] year-old female admitted to facility on 05/26/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Quarterly MDS, dated [DATE], reflected resident had severely impaired cognitive skills for daily decision making and requires a mechanically altered diet. Review of Resident #3's September 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Care Plan, dated 05/21/21, reflected: Focus: Resident is at risk for weight loss/gain, impaired skin or pressure areas related to nutritional deficits: 1. Mechanical soft consistency diet Initiated on 06/12/17 and revised on 02/06/19. The Care Plan did not address the change to a pureed diet. Focus: Behaviors: Resident is at risk for social isolation, impaired dignity, weight loss/gain, related to: 1. Resistive to care 2. Verbal behavioral symptoms directed towards others 3. Resident likes to go to bed in her clothes and not take off her shoes, she likes to lay on top of the covers 4. 9/26/18: resident becomes very anxious when her routine is upset, i.e. other resident attempt to sit at her dining table 5. 8/12/19: verbalizing non truths about staff Date initiated: 03/20/18 Revision on: 08/12/19 During interviews with charge nurse, MDS Nurse, DON and ADM, (as described below), the resident no longer displays these behaviors. Focus: Resident showing affection and or intimacy toward another resident. 1. Resident noted in dining room kissing other resident 2. Resident noted spending time in other resident's room sitting aside of each other and holding hands or just talking Date Initiated: 08/09/19 During interviews with charge nurse, MDS Nurse, DON and ADM, (as described below), the resident no longer displays these behaviors. Review of the facility's Diet Type Report, dated 09/07/21, documented Resident #3 had a Diet Type of LCS, Diet Texture of Pureed and Fluid Consistency of Regular/Thin. Resident#3 was observed on 09/07/21 at 5:51 PM during meal service being fed by unidentified CNA Resident #3 was seated at a u-shaped table with another resident at the other end of the table. Resident #3 had a pureed diet. Resident #3 was calm and did not appear anxious that another person was seated at her table which was one of the behaviors identified in the Care Plan. Review of Resident #18's Face Sheet, dated 09/09/21, reflected she was an [AGE] year-old female admitted to facility 02/21/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the September physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #18's Care Plan, dated 07/09/21, revealed the care plan did not address Resident #18's order for Lorazepam prior to showers and did not have interventions for dealing with behaviors during the shower. The Care Plan and R #18's latest MDS also did not indicate that Resident #18 should be transferred via mechanical lift although staff was using a lift to do her transfers. An observation on 09/09/21 at 8:36 AM revealed CNA D and CNA C transferred Resident #18 via mechanical lift. During an interview on 09/10/21 at 10:12 AM, LVN B stated she had been in the MDS position since this past April but had worked in facility for about [AGE] years. LVN B stated the purpose of the care plan was to lay out how we care for the resident. LVN B further explained how they schedule care plan meetings and then acknowledged sometimes things get overlooked but things do need to be resolved and we need to clean them up as we do them. LVN B acknowledged that Resident #3 and #18's care plans need to be audited and updated since changes had not been made since 2019 and no longer accurately reflected the current needs of these residents. LVN B stated nursing managers along with Restorative Aides did weekly meetings to discuss changes in residents and the Restorative Aide assisted with communicating changes to line staff. LVN B also stated that CNAs could access the care plan in their kiosks. If the care plans are not correct, then CNAs would not have accurate information to provide care to the residents. During an interview on 09/10/21 at 10:36 AM, the DON stated the purpose of the care plan was that someone should be able to pull up the care plan and see if there have been changes or falls. See it as a guide to care. The DON stated that the CNAs should be able to see the care plan on their kiosks. The DON acknowledged that Resident #3 had had a decline and was now total care. The DON stated that although Resident #18 still wandered she didn't put on makeup and did not exhibit behaviors listed in care plan. The DON further explained they have weekly Standard of Care meetings which included the Restorative Aides and they reviewed changes in residents and these changes should be recorded in the care plan to provide accurate written information to staff providing the care. During an interview on 09/10/21 at 10:48 AM, CMA E stated that Resident #18 sometimes wanders down the hall in her wheelchair but no longer goes into residents' rooms. She also usually held a baby or stuffed bear. The nurse gave Resident #18 the medication prior to her shower. CMA E also stated that Resident #3 was unable to wander in her wheelchair. During an interview on 09/10/21 at 11:00 AM, LVN F stated the Lorazepam helps calm down Resident #18 since she gets grabby and skittish in the shower. The shower aide tells the nurse when they were going to give the shower so she can be pre-medicated. LVN F stated Resident #18 and another resident often just go to the end of the hall together and sometimes go in the last room but she no longer wanders into other residents' rooms. LVN F stated that Resident #3 has not been the same since she had COVID in January. LVN F then stated that Resident #3 had just been placed on hospice this week. During an interview on 09/10/11 at 1:00 PM, the ADM stated the purpose of the care plan is to make sure the resident has been mirrored so that one knows the resident's habits or change of condition. The IDT (Interdisciplinary Team) should be looking at the care plan for changes in routines. The CNAs should be aware of what is in the care plans which they have on their kiosks. ADM also stated the CNAs tell us about residents who have certain needs. ADM stated that anyone should be able to look at the Care Plan and identify the resident as described so proper care can be given. Review of the facility's undated Comprehensive Care Plans policy reflected: 1. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being b. Any services that would otherwise be required but are not provided due to a resident exercising their right to refuse treatment and services.

Based on interview and record review, the facility failed to employ a qualified individual to direct its activities program. The facility has been without a qualified individual to direct its activities program since June 2021. This failure could result in the activity interests of all residents not being met. Findings: Personnel file review on 09/10/21 revealed that the facility's current Activity Director (AD) was not currently certified. The previous certified AD's last day in the facility was 06/21/21. During interview at 8:35 A.M. on 09/10/21, the AD stated that she took over this position on 07/16/21. She stated that she enrolled in an AD certification course in July 2021 and that the course would take approximately six months to complete. During interview at 8:45 A.M. on 09/10/21, the facility Administrator confirmed that the facility did not currently employ an individual that met the qualifications to direct its activities program.

Based on interviews and record review, the facility failed to provide services in accordance with the resident's written plan of care to meet professional standards of quality for one (Resident #1) of five residents reviewed for Assessments. Resident #1's assessment was not documented after an incident was reported to the facility. This failure places the resident at risk of neglect, injury, and a decrease in quality of life. Findings included: Resident #1's facesheet, dated 08/13/19, reflected an [AGE] year old female, admitted to the facility 03/19/18. [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 05/01/19, reflected a BIMS Score of four indicating severe cognitive deficits. Resident #1 required extensive assistance for all ADLs with a one or two physical assist. Review of the Provider Investigation Report dated 08/13/19, reflected Resident #1 began expressing pain in the left knee 8/4/19. Resident was assessed and demonstrated no bruising to the knee and full ROM. Resident was given pain medication. On 8/5/19 an x-ray was ordered with negative results. A second x-ray was ordered on [DATE] after it was discovered the first x-ray was of the wrong knee. The second x-ray confirmed a fracture to the left tibia. Through staff interviews it was discovered that CNA B had been pushing Resident #1 in her wheelchair on 8/4/19 when the resident dropped her foot from the wheelchair foot pedal and yelled in pain. CNA B was suspended pending the outcome of the investigation, which the facility found to be inconclusive for abuse or neglect. Resident #1's x-ray, dated 08/06/19, reflected a fractured proximal aspect of the tibia of the left knee. Record Review of Resident #1's assessments reflected no assessment, dated for 8/4/19, for pain and injury. Record Review of Resident #1's care plan, initiated 3/19/18, reflected, Resident is at risk for decreased socialization, weight loss and altered mood states related to pain and discomfort related to: decreased mobility .Resident will verbalize pain relief or acceptable pain control . Interventions included, Assess/document and treat for non verbal signs and symptoms of pain or discomfort: facial grimacing, guarding to specific area .Assess/document/treat for pain and discomfort. Assess for root cause of pain . Interview on 8/13/19 at 4:00 PM with LVN A revealed, My CNAs notified me of what happened (on 8/4/19). I was not present when the incident occurred. When I got to the resident, she was still in her wheelchair. I did ROM exercises on the left leg. The left foot was still out of the pedal. I didn't see any swelling or redness on her ankle. She expressed no pain. LVN A stated that she stopped and assessed the resident 10-15 minutes later when Resident #1 was in bed. There was no redness, abrasion or bruising on the leg at the time. She also stated, I would have called the doctor and requested an x-ray if it was needed but I got called into another resident's room who was bleeding. When asked about the assessment being documented, LVN A stated that she did not document the incident or the assessment but knows that she should have done so. Once she was called into the other resident's room, she got distracted and forgot. Interview on 8/13/19 at 10:20 AM with NP revealed that she became aware of Resident #1's pain on 8/5/19 when she saw the resident in her room. She ordered an x-ray and when the x-ray revealed a fracture she sent Resident #1 to the hospital. NP was not notified of the incident that occurred on 8/4/19. Interview on 8/13/19 at 4:41 PM with CNA B revealed that the day of the incident she was pushing Resident #1 to her room. Before they got to Resident #1's room, Resident #1's foot got hung up on the wheelchair foot pedal and the resident screamed. CNA B stated Resident #1 had dropped her foot from the pedal. CNA B stated that the resident's foot was secure on the wheelchair pedal when they left the dining room. She immediately notified the charge nurse who came and assessed pain. CNA B, with the help of another aide, took Resident #1 to her room and transferred her from the wheelchair to the bed with a hoyer lift. When they put her on the bed, she moaned in pain. Interview on 8/13/19 at 3:55 PM with LVN C revealed in the event of an incident that involves a resident, protocol includes knowing how the incident occurred, applying first aide if needed, notifying the doctor, family, and DON. If the doctor requests orders the charge nurse would follow the orders. For falls, witnessed, or unwitnessed incidents the charge nurse initiates neurological checks. I would do an entire assessment if they had a fall or incident in which they hurt themselves. If the incident is witnessed by staff you get the statement and write it on the incident report. On the incident report, we say what our action was, if statements were taken, and interventions. Also if there were any environmental factors that contributed to the incident. The assessment is put on the incident report. I sign off on the incident report which goes to the DON. Interview on 8/13/19 at 5:00 PM with DON revealed his expectation for charge nurses when doing assessments is to document those assessments. He stated, The charge nurses will be documenting anything unusual from now on. (LVN A) should have documented the assessment/ROM evaluation in her progress notes. Based on the information, it didn't appear to be an incident but she could have written it down on an incident report. I'd rather her over report than not at all. The DON went on to say having the incident report would have likely helped because by the time x-ray results revealed a fracture, he didn't have much to go on. The DON stated he had spoken with LVN A on 8/4/19 but Resident #1 did not come up in the conversation. Interview on 8/13/19 at 5:09 PM with the Administrator revealed his expectations in the event of incident, witnessed or unwitnessed was that the CNA notify the charge nurse so the resident can be assessed. The charge nurse then notifies the DON and MD. If there is any suspicion of abuse or neglect staff will notify the Administrator immediately or DON if the Administrator can't be reached. The facility debated whether or not to suspend the CNA once they discovered the incident occurred on 8/4/19. They found in their investigation that allegations of abuse/neglect were inconclusive. Normally the incident would be reported and they would investigate that but they worked backwards with this investigation which started from notification of the fracture. If they had discovered the incident before the fracture then they would have immediately reported it as suspected abuse. Staff should be documenting any and all things relevant to the resident's condition. Review of the facility policy Change in Resident Condition, date unknown, reflected, This facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status .1. 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 .3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider .7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from the administration of unnecessary drugs (which indicate the dose should be reduced or discontinued/for excessive duration/without indications for use/), for one (Resident # 12) of five residents reviewed for unnecessary medications. The facility did not obtain a rationale from Resident #12's physician for continuing the use of an antidepressant medication. This failure could place Resident #12 and other residents receiving antidepressants at risk for adverse drug consequences. Findings include: Review of Resident #12's face sheet revealed an [AGE] year old female admitted on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #12's Quarterly MDS dated dated 12/26/2018 revealed a BIMS score of 11 which indicates mildly impaired cognition. The MDS assessment also revealed the resident had a diagnoses of Anxiety and Depression. Review of Resident # 12's Care plan dated 1/3/2019 addressed anxiety. The resident uses antidepressant medication related to Poor Nutrition. Review of Resident #12 clinical records revealed no diagnoses of depression. Record review of Resident #12's Physician order [REDACTED]. ([MEDICATION NAME] is an antidepressant and can also be used as an appetite stimulant). Record review of Resident #12's Physician order [REDACTED]. Record review of Resident #12's Medication Regimen dated 11/20/2018 revealed the pharmacist recommended possible dose reduction for [MEDICATION NAME] 15 mg, 1 tablet PO QHS for appetite stimulant. Review of Nurse Practitioner Report dated 11/05/2018 revealed, Resident #12 is eating OK despite of change of diet. Very Pleasant, anxiety controlled. Record review of weights revealed the following: 3/8/2019 12:15 150.4 Lbs 2/5/2019 15:18 151.4 Lbs 1/4/2019 15:33 147.8 Lbs 12/5/2018 15:14 149.4 Lbs 11/30/2018 11:09 148.4 Lbs 11/27/2018 12:15 147.6 Lbs Wheelchair 11/16/2018 13:31 146.8 Lbs 11/9/2018 15:52 145.2 Lbs 11/2/2018 11:12 146.8 Lbs 10/5/2018 14:54 152.0 Lbs 9/6/2018 10:41 147.0 Lbs 8/3/2018 09:55 141.2 Lbs 7/8/2018 10:34 140.6 Lbs 6/22/2018 14:58 143.8 Lbs 6/22/2018 11:30 143.8 Lbs Wheelchair 6/12/2018 11:57 142.2 Lbs 6/8/2018 12:23 142.2 Lbs Wheelchair 6/4/2018 12:50 140.2 Lbs 6/1/2018 11:59 140.0 Lbs Wheelchair 5/25/2018 16:06 138.2 Lbs 5/25/2018 13:14 138.2 Lbs Wheelchair 5/18/2018 15:51 138.6 Lbs 5/18/2018 09:27 138.6 Lbs Standing 5/16/2018 13:19 141.0 Lbs Wheelchair 5/14/2018 09:34 141.0 Lbs Wheelchair 5/11/2018 15:05 141.0 Lbs 5/11/2018 11:40 140.0 Lbs Wheelchair 5/9/2018 13:43 138.0 Lbs Wheelchair 5/7/2018 11:55 138.6 Lbs Wheelchair 5/7/2018 09:41 136.0 Lbs 5/4/2018 10:13 136.0 Lbs Wheelchair 4/30/2018 15:43 137.2 Lbs 4/30/2018 12:36 137.2 Lbs Wheelchair Record review of Resident #12's clinical record reflected a Body Mass Index (BMI) of 24.3 and height of 66 inches. Underweight less than 18.5 Normal Weight 18.5 - 24.9 Overweight 25 - 29.9 Obesity (Class 1) 30 - 34.9 Extreme Obesity (Class 3) 40+ Record review of Dietary Quarterly Review dated 11/20/2018 revealed Resident #12's average daily meal intake was between 51-75% and there were no significant weight changes. Record review of Dietary Quarterly Review dated 12/26/2018 revealed Resident #12's average daily meal intake was between 51-75% and there were no significant weight changes. Record review of Dietary Quarterly Review dated 03/27/2019 revealed Resident #12's average daily meal intake was between 51-75% and there were no significant weight changes. During an interview 04/03/19 12:06 PM, the MDS coordinator stated there was a mistake and that Resident #12 does not have Depression but has Anoxia. During an interview on 04/03/19 12:33 PM, the DON stated Resident #12 does not have a [DIAGNOSES REDACTED]. She also stated there is not a reason why Resident #12 is on [MEDICATION NAME], and furthermore, there was no reason why Resident #12's [MEDICATION NAME] got increased from 15mg to 30 mg. During an interview on 04/03/19 01:28 PM, the DON stated there were no nurses notes indicating any changes in Resident #12's appetite or mood. There was also no record of a gradual dose reduction. During an interview on 04/03/2019 1:48PM, the NP stated she got documentation about Resident #12's mood and appetite from the nurses at the facility. She also stated she did not know why Resident #12's [MEDICATION NAME] was increased from 15mg to 30 mg. She further stated her documentation indicated that Resident #12's mood was stable and her weight was noted to be increasing. During an interview on 04/03/2019 2:28PM, LVN A stated Resident #12's eating behavior was adequate to below average and she averages about 50% of each of her meals. She stated Resident #12 does not have any frequent appetite issues and no weight issues or concerns. She also stated if residents have weight issues they get an alert or if they refuse to eat they offer health shakes. She then stated if she notifies the doctor she would document it in point click care. Review of Senior Care Management, LLC [MEDICAL CONDITION] Drugs policy, given by the DON revealed the following: Is it the policy of this facility to appropriately utilize and monitor the use of [MEDICAL CONDITION] drugs throughout the tenure of a residents stay. To accomplish the successful implementation of this policy, the facility will use its established Quality Assurance Performance Improvement ( QAPI) Program to monitor their use. The facility will ensure, through a comprehensive assessment of a resident, the following: 1. Residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. 2. Residents who use [MEDICAL CONDITION] drugs will receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Based on observations, interviews, and record reviews, the facility failed to prepare foods according to the established food preparation practices and safety techniques in 1 of 1 kitchen as evidenced by: A. Two packaged tubes of thawing uncooked pork loins in a container stored next to a box of packaged fully cooked ham, two unopened boxes of Glucerna shakes, and a partially opened box of bananas on the bottom shelf on the walk-in refrigerator. B. A sanitizer spray bottle hanging next to boxes of beverage pouches hooked up to the juice machine and sanitizer buckets with sanitizing solution stored next to boxes of beverage pouches and plastic food storage containers on the bottom shelf of food prep counters. C. A cook failed to properly perform hand hygiene after touching the lid of a trash can and continued with food preparations. These deficient practices could place 66 residents at risk for food contamination, gastrointestinal illnesses, and foodborne illnesses. The findings include: A. Observations on 03/13/18 at 10:13 AM, revealed two packaged tubes of thawing uncooked pork loins in a container were stored next to a box of packaged fully cooked ham, two unopened boxes of Glucerna shakes, and a partially opened box of bananas on the bottom shelf on the walk-in refrigerator. During an interview on 03/13/18 at 10:15 AM, the Dietary Manager (DM) stated she checked for cross contamination Monday thru Friday, and the cooks checked on the weekends. The DM further stated thawing meats were stored on the bottom shelf of the walk-in. The DM further stated veggies, fruits, leftovers, milk would be stored on separate shelves. Record review on 03/15/18 at 02:56 PM of the facility Storage of Food in Refrigeration policy, revealed store raw meats on the bottom shelves to prevent contamination of other perishable items. Review of the Texas Food Establishment Rules, dated (MONTH) (YEAR), section 228.66(a)(1)(A)(ii), revealed: food shall be protected from cross contamination by: separating raw animal foods during storage, preparation, holding, and display from: other raw ready-to-eat food such as vegetables and cooked ready-to-eat food. B. Observations on 03/13/18 at 10:23 AM, revealed one spray bottle of Sanitizer hanging next to several boxes of beverage pouches on the bottom shelf. Further observations revealed two sanitizer buckets with sanitizing solution stored next to boxes of beverage pouches on the bottom shelf. Observations on 3/14/18 at 9:47 AM and 9:53 AM, revealed two sanitizer buckets with sanitizing solution stored next to boxes of beverage pouches and next to plastic food storage containers on the bottom shelf of a food prep counter. During an interview on 03/14/18 at 09:47 AM, the DM stated they have a chemical closet. The DM stated the staff prepare the sanitizer buckets with sanitizing solution and store them on any bottom shelf. The DM further stated there was no designated area for the storing the sanitizer buckets. Record review on 03/15/18 at 03:02 PM of the facility Non-Food Storage policy, revealed chemicals currently in use (disinfectant/sanitizer) must be stored away from open sources. Review of the Texas Food Establishment Rules, dated (MONTH) (YEAR), section 228.68(d)(5), revealed: containers of chemical sanitizing solutions shall be stored off the floor and used in a manner that prevents contamination of food, equipment, utensils, linens, single-service, or single-use articles. C. Observations on 03/14/18 at 09:57 AM, revealed Cook A lifted a trashcan lid with his hands to throw away a paper towel after washing his hands and continued on with food preparations without properly washing his hands again. During an interview on 03/14/18 at 10:19 AM, the DM stated the staff were trained on hand washing through in-services. The DM further stated she would watch the staff after training to ensure they were [MEDICATION NAME] proper hand washing. The DM further stated she expected the staff to wash their hands before and after tasks, removing gloves, and touching face and other body parts. Record review on 03/15/18 at 03:04 PM of the facility Food Safety policy, revealed all food service staff will wash their hands upon entering the kitchen and when moving from one food prep area to another. Review of the Texas Food Establishment Rules, dated (MONTH) (YEAR), section 228.38(d)(9), revealed: food employees shall clean their hands and exposed portions of their arms as specified under subsection (b) immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (9) after engaging in other activities that contaminate the hands. The facility census was 66 per Administrator. Per CMS form 672, zero residents received their nutrition and hydration via tube feedings.

Based on observation, interview and record review the facility failed to ensure that resident's environment remained as free from accident hazards as possible when 3 of 6 residents (Resident #s 4, 5 and 6) reviewed for accidents were burned with hot coffee in excess of 120 degrees Farenheit (corporate recommended serving temperature). a) Resident # 4 sustained 2nd degree burns (partial thickness burns affecting both the outer and underlying layer of skin causing pain, redness, swelling and blistering) to both upper anterior and inner thighs on 11/7/11. b) Resident #5 sustained 2nd degree burns to the left forearm on 11/4/11. c) Resident 6 sustained 1st degree burns (affects only the outer layer of the skin causing pain, redness and swelling) to both upper thighs on 10/27/11. This deficient practice resulted in injuries to 3 residents and placed an additional 38 residents, who were care planned for minimal assistance with meals, at risk for injuries related to hot coffee. This resulted in an Immediate Jeopardy (IJ). While the IJ was removed on 11/10/11 the facility remained out of compliance at a potential for more than minimal harm at a pattern that is not an IJ because the facility administrative staff had not had time to develop, implement and monitor new policies and procedures or conduct all in-services outlined in their plan of removal. The findings include: a) Review of the admission face sheet dated 11/5/11 for Resident #4 reflected an admission date of [DATE]. Review of the admitting physician history and physical dated 11/2/11 for Resident #4 reflected the following Diagnoses: [REDACTED]. Review of the admission care plan dated 11/5/11 for Resident #4 reflected the following: 1. Resident self-propels wheelchair 2. Minimal assist of one person 3. Independent eating with only tray set-up required 4. Confused, oriented to person only. Review of a facility Accident/Incident report dated 11/7/11 for Resident #4 reflected resident sustained [REDACTED]. Review of the nurses notes dated 11/7/11 for Resident #4 reflected the following: 7:45 AM Resident spilled a cup of hot coffee on her lap in the dining room. 8:30 AM Redness noted to bilateral inner thighs. Medicated with Tylenol. 9:00 AM Area to inner thighs reassessed, blisters noted to area. Resident continues to complain of discomfort. Nurse Practitioner notified. Observation on 11/9/11 at 9:15 AM of Resident #4 revealed a large area of redness to both upper anterior and inner thighs with multiple small and large blisters, some intact and some open, to both thighs. Red area measured approximately 14 centimeters (cm) by 20 cm on the right upper thigh and approximately 15 cm by 26 cm on the left upper thigh. Multiple large and small blisters to both upper thighs. As staff removed residents pants for observations resident winced, grimaced and took a deep breath. In an interview on 11/9/11 at 10:30 AM Resident #4 stated she spilled the coffee from her breakfast into her lap. b) Review of the admission face sheet dated 3/22/11 for Resident #5 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the current care plan for Resident #5 reflected resident is dependent on from 1 or 2 staff for assistance with activities of daily living including eating, transferring, bathing and grooming due to blindness and muscle weakness. Review of the facility Incident/Accident report dated 11/4/11, no time documented, for Resident #5 reflected resident sustained [REDACTED]. Report incomplete with most areas left blank and does not indicate where on the resident's body the burns were. Report form sections that were to be completed by the Director of Nurses, including investigation findings and interventions were blank. Review of the nurse's notes for Resident #5 reflected the following: 11/4/11 4:00 PM Silvadine cream two times a day for one week to burn area until healed. 11/5/11 1:20 PM Checked area on upper abdomen and left arm where resident spilled coffee on self, very little light pink noted, no blisters. Observation on 11/9/11 at 10:00 AM of Resident #5 revealed no areas of redness or blisters to abdomen or arms. In an interview on 11/9/11 at 10:05 AM Resident #5 stated he spilled the coffee from his lunch meal on his arm and stomach. He further stated he had his coffee in one hand and reached with for something with his other hand and bumped the cup spilling his coffee. c) Review of the admission face sheet dated 8/9/11 for Resident #6 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the current care plan for Resident #6 reflected the following: Requires assistance of 1 staff member for set up of his meal trays due to blindness. Review of the nurses' notes for Resident #6 reflected the following: 10/27/11 7:15 AM Patient spilled hot coffee on herself, on her legs. Redness in both inner thighs. No blistering yet. 8:15 AM Lite pink remains in right inner thigh, left inner thigh remains slightly red. No blistering. 10/28/11 6:00 AM - 6:00 PM Follow-up hot coffee spill. No blisters, light pink noted 10/31/11 11:00 AM Inner right thigh still has a pink area. Right inner thigh has an area about 4 by 3 cm of white wrinkled skin where blisters had been. No drainage. Skin around white wrinkled skin remains slightly red. Review of the facility Incident/Accident report dated 10/27/11 for Resident #6 reflected resident spilled hot coffee on her legs. Redness in both inner thighs. No blistering yet. Further review of Section XIV, completed by the DON reflected the following: Conclusion: Resident spilled coffee on legs (in dining room), causing redness. New Interventions to Prevent Recurrence Coffee cup not to be full-to be placed on table for resident. In an interview on 11/9/11 at 1:00 PM the facility Administrator and DON stated the facility purchased a new coffee maker on 10/7/11. Kitchen staff were informed by the Administrator keep the coffee below 120 degrees (per facility corporate recommendations) serving temperature. The Administrator stated there were no recorded temperatures that had been taken since that time and that she did not check to ensure they were being done. She further stated she had instructed the Dietary Supervisor to contact the coffee maker company representative to lower the temperature settings on the machine and that this had not been done. The DON stated after Resident #5 and #6 sustained burns she instructed the staff to not fill the coffee cups to the top and to set the coffee on the table instead of letting the resident carry it while in their wheelchairs. She stated there are staff assigned to the dining room during meals however she had not monitored whether the staff were complying with placing the cups on the table with only half a cup of coffee. She further stated she did not know if the 3 residents who had been burned had obtained their own coffee from the facility coffee bar or if it had been served to them by a staff member. The DON stated she did not complete the investigations into the 3 incidents. Observation on 11/9/11 at 1:30 PM revealed residents in wheelchairs could not reach the coffee on the coffee bar without standing up. Observation on 11/9/11 at 1:40 PM revealed coffee temperatures taken by the Dietary Supervisor of a cup of coffee prior to placing the pot at the coffee bar was 162 degrees. In an interview on 11/9/11 at 1:40 PM the Dietary Supervisor stated she had instructed her staff to ensure coffee was below 120 degrees before serving however she had no documentation of any coffee temperatures being taken since the purchase of the new coffee maker in October. She further stated she had not called the coffee maker representative regarding the temperature adjustment. Review of the American Burn Association 'Time and temperature relationship to severe burns' reflected exposure to liquids with a temperature 140 degrees Farenheit will cause a second degree burn in 3 seconds. On 11/9/11 at 2:50 PM the Administrator, DON and Corporate Registered Nurse (RN) were informed of an IJ related to the failure to protect residents from injuries due to hot coffee burns. On 11/9/11 at 4:55 PM the Corporate RN provided the surveyor with a written plan of removal of the immediacy, which documented the following: A. Facility failed to ensure the environment was free of accidents/hazards, failed to evaluate, analyze and implement interventions and monitor an identified hazard. a. Administrative staff has been in-serviced on ensuring the environment is free of any accidents and hazards utilizing the incident report forms to investigate, and implement interventions to prevent reoccurrence of an identified hazard by the Clinical Compliance Nurse to be completed on 11/9/11. b. Compliance nurse will monitor all incidents on a monthly basis. c. Coffee carafes were removed from the dining room. d. Coffee will be cooled to a temperature of 118 degrees prior to serving to the residents beginning 11/9/11. e. A coffee temperature log has been implemented and the temperature of the coffee will be checked and logged prior to serving to the residents. f. All dietary staff currently working has been in-serviced on this new procedure, the others will be in-serviced prior to beginning their shift by the Dietary Supervisor and the Administrator to be completed by 11/10/11. g. The coffee temperature log will be reviewed during the morning meeting to ensure all temperatures are 118 degrees or less to be completed by the Administrator. Based on observations and interviews on 11/9/11 and 11/10/11 of staff being in-serviced on coffee temperatures, serving coffee to residents and incident investigation and reporting the surveyor informed the Administrator, DON and Corporate RN on 11/10/11 at 4:30 PM that the Immediacy no longer existed. However, the deficient practice remained at the level of potential for more than minimal harm at pattern that is not Immediate Jeopardy because the facility administrative staff had not had time to develop, implement and monitor all corrective actions outlined in their plan of removal. The facility DON provided the number of residents requiring minimal assistance with meals of 38.

Based on observation, interview and record review the facility failed to thoroughly investigate and report incidents of neglect to the appropriate in accordance with regulations when when 3 of 6 residents (Resident #s 4, 5 and 6) reviewed for accidents were burned with hot coffee as a result of failure to monitor coffee temperatures. a) Resident # 4 sustained 2nd [MEDICAL CONDITION](partial [MEDICAL CONDITION] both the outer and underlying layer of skin causing pain, redness, swelling and blistering) to both upper anterior and inner thighs on 11/7/11. b) Resident #5 sustained 2nd [MEDICAL CONDITION] the left forearm on 11/4/11. c) Resident 6 sustained 1st [MEDICAL CONDITION](affects only the outer layer of the skin causing pain, redness and swelling) to both upper thighs on 10/27/11. This deficient practice resulted in injuries to 3 residents and placed an additional 38 residents, who were care planned for minimal assistance with meals, at risk for injuries related to hot coffee. Failure to thoroughly investigate and report incidents of neglect has the potential to prevent the development and implementation of policies and procedures to ensure resident safety. This resulted in an Immediate Jeopardy (IJ). While the IJ was removed on 11/10/11 the facility remained out of compliance at a potential for more than minimal harm at a pattern that is not an IJ because the facility administrative staff had not had time to develop, implement and monitor new policies and procedures or conduct all in-services outlined in their plan of removal. The findings include: a) Review of the admission face sheet dated 11/5/11 for Resident #4 reflected an admission date of [DATE]. Review of the admitting physician history and physical dated 11/2/11 for Resident #4 reflected the following Diagnoses: [REDACTED]. Review of the admission care plan dated 11/5/11 for Resident #4 reflected the following: 1. Resident self-propels wheelchair 2. Minimal assist of one person 3. Independent eating with only tray set-up required 4. Confused, oriented to person only. Review of a facility Accident/Incident report dated 11/7/11 for Resident #4 reflected resident sustained [REDACTED]. Review of the nurses notes dated 11/7/11 for Resident #4 reflected the following: 7:45 AM Resident spilled a cup of hot coffee on her lap in the dining room. 8:30 AM Redness noted to bilateral inner thighs. Medicated with Tylenol. 9:00 AM Area to inner thighs reassessed, blisters noted to area. Resident continues to complain of discomfort. Nurse Practitioner notified. Observation on 11/9/11 at 9:15 AM of Resident #4 revealed a large area of redness to both upper anterior and inner thighs with multiple small and large blisters, some intact and some open, to both thighs. Red area measured approximately 14 centimeters (cm) by 20 cm on the right upper thigh and approximately 15 cm by 26 cm on the left upper thigh. Multiple large and small blisters to both upper thighs. As staff removed residents pants for observations resident winced, grimaced and took a deep breath. In an interview on 11/9/11 at 10:30 AM Resident #4 stated she spilled the coffee from her breakfast into her lap. b) Review of the admission face sheet dated 3/22/11 for Resident #5 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the current care plan for Resident #5 reflected resident is dependent on from 1 or 2 staff for assistance with activities of daily living including eating, transferring, bathing and grooming due to [MEDICAL CONDITION] and muscle weakness. Review of the facility Incident/Accident report dated 11/4/11, no time documented, for Resident #5 reflected resident sustained [REDACTED]. Report incomplete with most areas left blank and does not indicate where on the resident's body [MEDICAL CONDITION]. Report form sections that were to be completed by the Director of Nurses, including investigation findings and interventions were blank. Review of the nurse's notes for Resident #5 reflected the following: 11/4/11 4:00 PM Silvadine cream two times a day for one week to burn area until healed. 11/5/11 1:20 PM Checked area on upper abdomen and left arm where resident spilled coffee on self, very little light pink noted, no blisters. Observation on 11/9/11 at 10:00 AM of Resident #5 revealed no areas of redness or blisters to abdomen or arms. In an interview on 11/9/11 at 10:05 AM Resident #5 stated he spilled the coffee from his lunch meal on his arm and stomach. He further stated he had his coffee in one hand and reached with for something with his other hand and bumped the cup spilling his coffee. c) Review of the admission face sheet dated 8/9/11 for Resident #6 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the current care plan for Resident #6 reflected the following: Requires assistance of 1 staff member for set up of his meal trays due to [MEDICAL CONDITION]. Review of the nurses' notes for Resident #6 reflected the following: 10/27/11 7:15 AM Patient spilled hot coffee on herself, on her legs. Redness in both inner thighs. No blistering yet. 8:15 AM Lite pink remains in right inner thigh, left inner thigh remains slightly red. No blistering. 10/28/11 6:00 AM - 6:00 PM Follow-up hot coffee spill. No blisters, light pink noted 10/31/11 11:00 AM Inner right thigh still has a pink area. Right inner thigh has an area about 4 by 3 cm of white wrinkled skin where blisters had been. No drainage. Skin around white wrinkled skin remains slightly red. Review of the facility Incident/Accident report dated 10/27/11 for Resident #6 reflected resident spilled hot coffee on her legs. Redness in both inner thighs. No blistering yet. Further review of Section XIV, completed by the DON reflected the following: Conclusion: Resident spilled coffee on legs (in dining room), causing redness. New Interventions to Prevent Recurrence Coffee cup not to be full-to be placed on table for resident. In an interview on 11/9/11 at 1:00 PM the facility Administrator and DON stated the facility purchased a new coffee maker on 10/7/11. Kitchen staff were informed by the Administrator keep the coffee below 120 degrees (per facility corporate recommendations) serving temperature. The Administrator stated there were no recorded temperatures that had been taken since that time and that she did not check to ensure they were being done. She further stated she had instructed the Dietary Supervisor to contact the coffee maker company representative to lower the temperature settings on the machine and that this had not been done. The DON stated after Resident #5 and #6 [MEDICAL CONDITION] instructed the staff to not fill the coffee cups to the top and to set the coffee on the table instead of letting the resident carry it while in their wheelchairs. She stated there are staff assigned to the dining room during meals however she had not monitored whether the staff were complying with placing the cups on the table with only half a cup of coffee. She further stated she did not know if the 3 residents who had been burned had obtained their own coffee from the facility coffee bar or if it had been served to them by a staff member. The DON stated she did not complete the investigations into the 3 incidents. Failure to thoroughly investigate incidents and implement preventative measures contributed to the subsequent injuries to Residents 4 and 5. Observation on 11/9/11 at 1:30 PM revealed residents in wheelchairs could not reach the coffee on the coffee bar without standing up. Observation on 11/9/11 at 1:40 PM revealed coffee temperatures taken by the Dietary Supervisor of a cup of coffee prior to placing the pot at the coffee bar was 162 degrees. In an interview on 11/9/11 at 1:40 PM the Dietary Supervisor stated she had instructed her staff to ensure coffee was below 120 degrees before serving however she had no documentation of any coffee temperatures being taken since the purchase of the new coffee maker in October. She further stated she had not called the coffee maker representative regarding the temperature adjustment. Review of the American Burn Association 'Time and temperature relationship to severe burns' reflected exposure to liquids with a temperature 140 degrees Farenheit will cause a second degree burn in 3 seconds. On 11/9/11 at 2:50 PM the Administrator, DON and Corporate Registered Nurse (RN) were informed of an IJ related to the failure to protect residents from injuries due to hot coffee burns. On 11/9/11 at 4:55 PM the Corporate RN provided the surveyor with a written plan of removal of the immediacy, which documented the following: A. Facility failed to ensure the environment was free of accidents/hazards, failed to evaluate, analyze and implement interventions and monitor an identified hazard. a. Administrative staff has been in-serviced on ensuring the environment is free of any accidents and hazards utilizing the incident report forms to investigate, and implement interventions to prevent reoccurrence of an identified hazard by the Clinical Compliance Nurse to be completed on 11/9/11. b. Compliance nurse will monitor all incidents on a monthly basis. c. Coffee carafes were removed from the dining room. d. Coffee will be cooled to a temperature of 118 degrees prior to serving to the residents beginning 11/9/11. e. A coffee temperature log has been implemented and the temperature of the coffee will be checked and logged prior to serving to the residents. f. All dietary staff currently working has been in-serviced on this new procedure, the others will be in-serviced prior to beginning their shift by the Dietary Supervisor and the Administrator to be completed by 11/10/11. g. The coffee temperature log will be reviewed during the morning meeting to ensure all temperatures are 118 degrees or less to be completed by the Administrator. Based on observations and interviews on 11/9/11 and 11/10/11 of staff being in-serviced on coffee temperatures, serving coffee to residents and incident investigation and reporting the surveyor informed the Administrator, DON and Corporate RN on 11/10/11 at 4:30 PM that the Immediacy no longer existed. However, the deficient practice remained at the level of potential for more than minimal harm at pattern that is not Immediate Jeopardy because the facility administrative staff had not had time to develop, implement and monitor all corrective actions outlined in their plan of removal. The facility DON provided the number of residents requiring minimal assistance with meals of 38.

Based on observation, interview and record review the facility Administrator and Director of Nurses (DON) failed to administer the facility in a manner to prevent injuries to residents when 3 of 6 residents (Resident #s 4, 5 and 6) reviewed for accidents were burned with hot coffee in excess of 120 degrees Farenheit (corporate recommended serving temperature). -Administrator failed to supervise and monitor the Dietary Manager to ensure kitchen procedures and instructions were followed and failed to supervise and monitor the DON to ensure appropriate investigation and reporting procedures were followed. -DON failed to thoroughly investigate incidents and ensure appropriate interventions were implemented and failed to supervise and monitor staff. a) Resident # 4 sustained 2nd [MEDICAL CONDITION](partial [MEDICAL CONDITION] both the outer and underlying layer of skin causing pain, redness, swelling and blistering) to both upper thighs on 11/7/11. b) Resident #5 sustained 2nd [MEDICAL CONDITION] the left forearm on 11/4/11. c) Resident 6 sustained 1st [MEDICAL CONDITION](affects only the outer layer of the skin causing pain, redness and swelling) to both upper thighs on 10/27/11. This deficient practice resulted in injuries to 3 residents and placed an additional 38 residents, who were care planned for minimal assistance with meals, at risk for injuries related to hot coffee. This resulted in an Immediate Jeopardy (IJ). While the IJ was removed on 11/10/11 the facility remained out of compliance at a potential for more than minimal harm at a pattern that is not an IJ because the facility administrative staff had not had time to develop, implement and monitor new policies and procedures or conduct all in-services outlined in their plan of removal. The findings include: a) Review of the admission face sheet dated 11/5/11 for Resident #4 reflected an admission date of [DATE]. Review of the admitting physician history and physical dated 11/2/11 for Resident #4 reflected the following Diagnoses: [REDACTED]. Review of the admission care plan dated 11/5/11 for Resident #4 reflected the following: 1. Resident self-propels wheelchair 2. Minimal assist of one person 3. Independent eating with only tray set-up required Review of a facility Accident/Incident report dated 11/7/11 for Resident #4 reflected resident sustained [REDACTED]. Review of the nurses notes dated 11/7/11 for Resident #4 reflected the following: 7:45 AM Resident spilled a cup of hot coffee on her lap in the dining room. 8:30 AM Redness noted to bilateral inner thighs. Medicated with Tylenol. 9:00 AM Area to inner thighs reassessed, blisters noted to area. Resident continues to complain of discomfort. Nurse Practitioner notified. Observation on 11/9/11 at 9:15 AM of Resident #4 revealed a large area of redness to both upper anterior and inner thighs with multiple small and large blisters, some intact and some open, to both thighs. Red area measured approximately 14 centimeters (cm) by 20 cm on the right upper thigh and approximately 15 cm by 26 cm on the left upper thigh. Multiple large and small blisters to both upper thighs. As staff removed residents pants for observations resident winced, grimaced and took a deep breath. In an interview on 11/9/11 at 10:30 AM Resident #4 stated she spilled the coffee from her breakfast into her lap. b) Review of the admission face sheet dated 3/22/11 for Resident #5 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the current care plan for Resident #5 reflected resident is dependent on from 1 or 2 staff for assistance with activities of daily living including eating, transferring, bathing and grooming due to [MEDICAL CONDITION] and muscle weakness. Review of the facility Incident/Accident report dated 11/4/11, no time documented, for Resident #5 reflected resident sustained [REDACTED]. Report incomplete with most areas left blank and does not indicate where on the resident's body [MEDICAL CONDITION]. Report form sections that were to be completed by the Director of Nurses, including investigation findings and interventions were blank Review of the nurse's notes for Resident #5 reflected the following: 11/4/11 4:00 PM Silvadine cream two times a day for one week to burn area until healed. 11/5/11 1:20 PM Checked area on upper abdomen and left arm where resident spilled coffee on self, very little light pink noted, no blisters. Observation on 11/9/11 at 10:00 AM of Resident #5 revealed no areas of redness or blisters to abdomen or arms. In an interview on 11/9/11 at 10:05 AM Resident #5 stated he spilled the coffee from his lunch meal on his arm and stomach. He further stated he had his coffee in one hand and reached with for something with his other hand and bumped the cup spilling his coffee. c) Review of the admission face sheet dated 8/9/11 for Resident #6 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the current care plan for Resident #6 reflected the following: Requires assistance of 1 staff member for set up of his meal trays due to [MEDICAL CONDITION]. Review of the nurses' notes for Resident #6 reflected the following: 10/27/11 7:15 AM Patient spilled hot coffee on herself, on her legs. Redness in both inner thighs. No blistering yet. 8:15 AM Lite pink remains in right inner thigh, left inner thigh remains slightly red. No blistering. 10/28/11 6:00 AM - 6:00 PM Follow-up hot coffee spill. No blisters, light pink noted 10/31/11 11:00 AM Inner right thigh still has a pink area. Right inner thigh has an area about 4 by 3 cm of white wrinkled skin where blisters had been. No drainage. Skin around white wrinkled skin remains slightly red. Review of the facility Incident/Accident report dated 10/27/11 for Resident #6 reflected resident spilled hot coffee on her legs. Redness in both inner thighs. No blistering yet. Further review of Section XIV, completed by the DON reflected the following: Conclusion: Resident spilled coffee on legs (in dining room), causing redness. New Interventions to Prevent Recurrence Coffee cup not to be full-to be placed on table for resident. In an interview on 11/9/11 at 1:00 PM the facility Administrator and DON stated the facility purchased a new coffee maker on 10/7/11. Kitchen staff were informed by the Administrator keep the coffee below 120 degrees serving temperature. The Administrator stated there were no recorded temperatures that had been taken since that time and that she did not check to ensure they were being done. She further stated she had instructed the Dietary Supervisor to contact the coffee maker company representative to lower the temperature settings on the machine and that this had not been done. The DON stated after Resident #5 and #6 [MEDICAL CONDITION] instructed the staff to not fill the coffee cups to the top and to set the coffee on the table instead of letting the resident carry it while in their wheelchairs. She stated there are staff assigned to the dining room during meals however she had not monitored whether the staff were complying with placing the cups on the table with only half a cup of coffee. She further stated she did not know if the 3 residents who had been burned had obtained their own coffee from the facility coffee bar or if it had been served to them by a staff member. The DON stated she did not complete the investigations into the 3 incidents. Observation on 11/9/11 at 1:30 PM revealed residents in wheelchairs could not reach the coffee on the coffee bar without standing up. Observation on 11/9/11 at 1:40 PM revealed coffee temperatures taken by the Dietary Supervisor of a cup of coffee prior to placing the pot at the coffee bar was 162 degrees. In an interview on 11/9/11 at 1:40 PM the Dietary Supervisor stated she had instructed her staff to ensure coffee was below 120 degrees before serving however she had no documentation of any coffee temperatures being taken since the purchase of the new coffee maker in October. She further stated she had not called the coffee maker representative regarding the temperature adjustment. Review of the American Burn Association 'Time and temperature relationship to severe burns' reflected exposure to liquids with a temperature 140 degrees Farenheit will cause a second degree burn in 3 seconds. On 11/9/11 at 2:50 PM the Administrator, DON and Corporate Registered Nurse (RN) were informed of an IJ related to the failure to protect residents from injuries due to hot coffee burns. On 11/9/11 at 4:55 PM the Corporate RN provided the surveyor with a written plan of removal of the immediacy, which documented the following: A. Facility failed to ensure the environment was free of accidents/hazards, failed to evaluate, analyze and implement interventions and monitor an identified hazard. a. Administrative staff has been in-serviced on ensuring the environment is free of any accidents and hazards utilizing the incident report forms to investigate, and implement interventions to prevent reoccurrence of an identified hazard by the Clinical Compliance Nurse to be completed on 11/9/11. b. Compliance nurse will monitor all incidents on a monthly basis. c. Coffee carafes were removed from the dining room. d. Coffee will be cooled to a temperature of 118 degrees prior to serving to the residents beginning 11/9/11. e. A coffee temperature log has been implemented and the temperature of the coffee will be checked and logged prior to serving to the residents. f. All dietary staff currently working has been in-serviced on this new procedure, the others will be in-serviced prior to beginning their shift by the Dietary Supervisor and the Administrator to be completed by 11/10/11. g. The coffee temperature log will be reviewed during the morning meeting to ensure all temperatures are 118 degrees or less to be completed by the Administrator. Based on observations and interviews on 11/9/11 and 11/10/11 of staff being in-serviced on coffee temperatures, serving coffee to residents and incident investigation and reporting the surveyor informed the Administrator, DON and Corporate RN on 11/10/11 at 4:30 PM that the Immediacy no longer existed. However, the deficient practice remained at the level of potential for more than minimal harm at a pattern that is not Immediate Jeopardy because the facility administrative staff had not had time to develop, implement and monitor all corrective actions outlined in their plan of removal. The facility DON provided the number of residents requiring assistance with meals of 38.

Based on observation, interviews and record review it was determined that for 1 of 16 sampled residents (Resident #1) the facility failed to ensure each resident received adequate supervision and assistive devices to prevent avoidable accidents for one resident with a history of falls; rendering her at risk for serious injury from falls. The facility failed to develop intervention strategies to prevent falls, monitor for changes that could contribute to Falls (Medications: Dilantin for treatment of [REDACTED]. Resident #1 had a history of [REDACTED]. Following each fall the facility neglected to thoroughly reassess after the fall to determine causal factors to develop preventive interventions to prevent falls. Resident #1 was sent to the hospital on [DATE] with altered mental status and it was documented she had a fall on this date also. On arrival to the emergency room it was discovered she had Dilantin (anti-convulsant) toxicity (high level of Dilantin). There was no laboratory test conducted from her admission to the facility on [DATE] to 08/22/10; although she had been on Dilantin medication for a history of seizures. The facility neglected to obtain resident labs; monitor the Dilantin levels that could contribute to falls. Following Resident #1's falls the facility failed to monitor for changes that could contribute to the falls (Medication Dilantin for treatment of [REDACTED]. Resident # 1's Dilantin levels remaining subtheraputic after this hospitalization . Resident # 1 fell on [DATE] in her room, complained of left hip, leg, elbow and shoulder pain and was transferred to the emergency room . She returned to the facility on [DATE] and the facility failed to obtain accurate emergency room [DIAGNOSES REDACTED]. Staff documented in the nurses notes Resident #1 had a left elbow fracture. Hospital records obtained by the surveyor on 11/16/10 revealed Resident #1 was diagnosed with [REDACTED]. The staff failed to identify and assess the pubic bone fracture or the concussion until 11/16/10. Resident #1 continues to complain of left leg and knee pain. With her Activity of Daily Living (ADL) levels having decreased due to the fall/injury of 11/01/10. Resident #1 was independent of most of her ADL's prior to the fall of 11/01/10 and now needs assistance with toileting and standing related to pain in the left leg and knee area. An Immediate Jeopardy (IJ) was identified on 11/16/10 at 1:10 PM. While the IJ was lowered to a non-immediate Jeopardy on 11/17/10 at 5:27 AM, the facility remained out of compliance at a pattern of Actual Harm because the facility had not yet in serviced all staff, implemented or evaluated their corrective action. The facility deficient practice could place any of the 78 residents in the facility that depend on nursing staff for accurate and timely assessments at risk for delay in or inappropriate medical treatment. Findings include: Review of the facility medical record for Resident #1 documented she was admitted on [DATE] with the Physician order [REDACTED]. Review of the Nurses Notes dated 04/25/10 revealed Resident #1 had a seizure. This was the last seizure documented in the nurse's notes. An Observation and interview on 11/15/10 at 2:20 PM Resident #1 appeared to be confused and drowsy. She was sitting in her wheelchair with her eyes closed, her chin on her chest and she spoke in a low voice during the interview. Surveyor checked the wheelchair and noted even when locked the wheels continued to move. Resident #1 stated she did not know what happened the day of the fall; she stated she just fell . Resident #1 stated she stills does not feel well; her leg and knee continues to hurt. Review of the accident/incident reports dated 11/01/10, 10/15/10, 09/19/10, 08/30/10, and 08/22/10 identified falls that occurred for Resident #1. Review of the Incident/Accident report dated 08/22/10 had documentation Resident #1 "fell while attempting to sit in the wheelchair when the wheelchair moved". Review of the nurses notes dated 08/21/10 late entry, Resident #1 " very sleepy all the time, is more Confused than usual also complained of right flank area discomfort " . Review of the Nurses Notes dated 08/22/10 had documentation that Resident #1 "fell at 0520 while attempting to change clothes and went to sit in the wheelchair with the wheels not locked and the chair rolled". The nurse ' s notes for 6AM/6PM had documentation that Resident #1 " was very sleepy and is more confused than usual " . Documentation at "1830 resident tearful shivering and confused. Family requested transfer to the hospital related to change of mental status". She was transferred by ambulance on 08/22/10 at 1915. Resident #1 was admitted to the hospital with [REDACTED]. The facility neglected to obtain resident labs; monitor the Dilantin levels that could contribute to falls. Following Resident #1's fall on 08/22/10 the facility failed to monitor for changes that could contribute to the falls (Medication Dilantin for treatment of [REDACTED]. Resident #1 was hospitalized returning to the facility on [DATE]. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. There was a Dilantin level ordered for 09/03/10 but not drawn until 09/17/10 which was 8.53 (below the normal). There was no evidence that the Dilantin medication given to prevent seizures were monitored or reviewed to determine if this was the possible cause of the resident ' s falls. Resident # 1's Dilantin levels remaining subtheraputic after this hospitalization . Review of the Incident/Accident report dated 08/30/10 documented Resident #1 "resident stated she went to the bathroom and walking back " falling to be "found lying on floor on right side". With this second fall the care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Review of the Incident/Accident report dated 09/19/10 Resident #1 fell (third fall) trying to get from her wheelchair to her bed. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Review of the Incident/Accident report dated 10/15/10 Resident #1 fell (fourth fall) while getting out of bed and going to the bathroom. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Only intervention was documented on the incident report "encourage resident to use call light for future super visional assistance with transfers". Resident # 1 fell (fifth fall) on 11/01/10 in her room, complained of left hip, leg, elbow and shoulder pain and was transferred to the emergency room . She returned to the facility on [DATE] and the facility failed to obtain accurate emergency room [DIAGNOSES REDACTED]. Staff documented in the nurses notes Resident #1 had a left elbow fracture. Hospital records obtained by the surveyor on 11/16/10 revealed Resident #1 was diagnosed with [REDACTED]. The staff failed to identify and assess the pubic bone fracture or the concussion until 11/16/10. Resident #1 continues to complain of left leg and knee pain. With her Activity of Daily Living (ADL) levels having decreased due to the fall/injury of 11/01/10. Resident #1 was independent of most of her ADL's prior to the fall of 11/01/10 and now needs assistance with toileting and standing related to pain in the left leg and knee area. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. There was no evidence that the Dilantin medication given to prevent seizures were monitored or reviewed for possible cause of the falls. In an interview on 11/15/10 at 3:15 PM CNA X and CNA Y stated Resident #1 was basically independent before the last fall. Now she needs assist to do activities of daily living. In an interview on 11/16/10 at 9:40 AM the Director of Nurses of the nursing home stated she was not aware of fall preventive measures in place for Resident #1 and the facility does not have a fall committee to address falls. She stated she had only been in the Director of Nurses position 3 weeks but was the Registered Nurses on East hall for 2 ? years. She was not aware of specific fall prevention measure used in the facility other than chair alarms and low beds. The DON further stated that fall risk assessments are to be completed quarterly and she did not know why Resident #1 had not had one done since 4/10. She stated she did not know about the care plan Review of the medical record on 11/16/10 for Resident #1 revealed the only fall risk assessment was completed on 04/10 upon admission and no other fall risk assessment was completed until 11/15/10 following surveyor ' s prompting. The 11/15/10 fall risk assessment scored Resident #1 at 15 which is high risk for falls. (A score of 10 or above represents high risks). Review of the quarterly undated and unsigned Minimum (MDS) data set [DATE] identifies a fall in the last 31-180 days. Review of the care plan dated 09/27/10 did not address the history of falls or fall preventive measures. There was a care plan addressing seizures which did not address the potential for falls. In an interview on 11/17/10 at 4:00 PM the Minimum Data Set (MDS) nurses stated they were updating MDS's and care plans. They stated the MDS ' s and care plans were behind as people have left and new staff was hired. Review of a undated facility "policy and procedure for Incident/Accidents Reports" provided by the ADON documented that a resident would be assessed for 72 hours after an incident and documentation would include the disposition with the date, resident ' s condition and the nurse's signature and put in the Director of Nurses door. The policy and procedure does not address fall preventive measures the facility can use. In an interview on 11/16/10 at 1:00 PM the attending physician for Resident #1 stated his expectations would include the staff to monitor for at least 72 hours after Resident #1 returned to the facility from the emergency room . He stated he felt that Resident #1 may be having petit mal seizures (minor epilepsy) because of the amount of falls she has had and that her Dilantin (anti-convulsant) is at subtherapeutic levels which could contribute to her falls. On 11/16/10 at 1:15 PM the facility's acting Administrator was informed that an Immediate Jeopardy existed due to the facility's failure to implement policies and procedures that prohibit neglect when the facility failed to prohibit neglect for one resident with a history of falls; rendering her at risk for serious injury from falls. The facility failed to develop intervention strategies to prevent falls, monitor for changes that could contribute to Falls (Medications: Dilantin for treatment of [REDACTED]. On 11/17/07 at 5:27 AM the facility provided surveyors with a written plan of removal which reflected the following: Failure to Prevent Neglect B1 and B4: The Director of Nurses and Assistant Director of Nurses or supervising RN will be notified of any injury to a resident as soon as possible after the charge nurse has assessed and evaluated the resident for any injury. This notification will be provided on a form that will be created and in place no later than December 1, 2010. This form will be kept in a binder in the Assistant Director of Nurses office. The following are the procedures that will be initiated as soon as the resident is stabilized. a. The physician is to be notified immediately of orders to treat any type of change of condition. b. The charge nurse will assess, notify and treat as the physician orders. c. The charge nurse will notify the MD and residents family of the incident. ? Assess the resident and document notification of the family and MD in the clinical record. ? Submit incident reports to the Administrator and Supervisor RN daily to determine need for further investigation. d. Following any falls, the resident will be referred to Physical Therapy (PT) for screening, evaluation, treatment and recommendations. ? MD will be notified of all injures and informed on signs and symptoms presented and orders received will be initiated and followed prescribed. ? Interdisciplinary Team (IDT) will meet to discuss appropriate interventions. ? IDT will review and revise Care Plan. e. A Fall Committee will be created to review all accidents and injuries weekly. Review, discuss and document conclusions and preventive measures. ? Based on Incident/Accident Report and MD orders, the nurses will evaluate. Assess, and document injuries or issues until resoled on each shift. Any unusual signs or symptoms may be addressed at this time. f. Nursing Staff will be in-serviced by Assistant Director of Nurses (ADON) beginning Thursday, November 18, 2010 and will be ongoing as necessary. The subjects will cover different systems that will include, but not limited to, Chart Audits, Lab Audits, Correcting Documentation errors, Prevent of Med Errors, Assessing resident change of conditions, Interpreting signs and symptoms of declining resident conditions, what to call into the Primary Care Physician (PCP) and what can be faxed to the PCP and other topics yet to be decided. ? The Nurse Aide ' s (CNA ' s) will be in-serviced on what to report to the charge nurse and when it needs to be reported, some things will need to be reported. B3 a. The charge nurses will receive new orders and will order meds, transcribe new orders onto the appropriate Medication and Treatment sheets and other forms as dictated by the order. b. The charge nurse will ensure Responsible Party is notified of new orders. c. The night shift charge nurses will audit the clinical records and MD orders to verify the orders are transcribed and documented properly on the related forms. Red ink will be used to indicate appropriate transcription. d. All current staff will be in-serviced starting on November 18, 2010 and completed by November 22, 2010. In-service will be conducted by the ADON on proper techniques for auditing, transcription and documentation entries of MD orders. All new hires will be orientated to the new Policies and Procedures. e. Any medication error reports will be completed as indicated and the person making the error will be counseled with further disciplinary action for repeat offenses or very serious errors that might jeopardize a residents well being. f. The charge nurse will notify and document in the clinical record that the family has been informed of any change of medication or treatment regime. B 11 a. Residents that have changes of condition will be assessed by the charge nurse. The charge nurse will notify the MD for treatment orders immediately after change of condition has been identified. b. Any changes in condition will be discussed in the daily stand-up meeting and interventions will be decided at this time. The supervising RN will be responsible for monitoring quality of care for all residents. Failure to protect from undue adverse medication consequences and /or failure to provide medications as prescribed. D 4 c. Staff will continue to be in-serviced on the dangers of medication errors and the effects of not administering medications as ordered and prescribed by a physician. These in-services will be presented by the ADON weekly beginning Thursday, November 18. 2010 and completed by November 22, 2010. d. This in-service training will be for the Medication Aides and the Nurses on a regular basis as appropriate. e. This training will include the ' 6 ' Rights of Medication Administration which includes documentation. This will ensure that staff is familiar and comfortable with this protocol. f. If a medication error occurs the Physician, Medical Director and the resident ' s Responsible Party will be notified. A medication error report will be initiated and the Policy and Procedure will be followed. g. The Medical Director will approve all Resident Care Policy and Procedures. h. Facility will request the Pharmacy Consultant to complete a medication audit as soon as possible and then at regular intervals thereafter. i. A Policy and Procedure will be put into place to address medication errors, the consequences and the effects on the elderly. j. Any newly adopted Policy and Procedure (P & P) will be approved by the Medical Director. k. The Medication Administration Record (MAR), Treatment Record, Insulin Sheets, Nebulizer Treatment Sheets, etc., will be printed a the least 8 days prior to the last day of the month for corrections as needed and double checking against the telephone orders and consolidated physician orders. l. All consolidated physician orders [REDACTED]. The Supervising RN or designee will be responsible to oversee that this is completed and correct. D 6 Many medications that residents receive must be monitored for appropriate levels in the blood to maintain adequate effectiveness. The PDR dictates what medications must be titrated and these labs must be done for each different medication on a regular schedule to ensure the effectiveness of the medication. The Labs for these medications are ordered by the physician and the physician must receive these labs in a timely manner. a. The Charge Nurse will receive the lab order, complete the Lab Requisition Form with all of the required information and place in the Lab Draw Book. b. Notification of the Physician will be based on lab results conveyed. Critical labs require immediate notification and response of the Physician for appropriate action. Appropriate documentation will be made in the clinical record by the Charge Nurse. c. A list of drugs that require titration will be requested from the pharmacy consultant and this list will be kept in the Lab Craw Book and a copy will be placed in the front of each Medication Administration Record (MAR). d. During the Quality Assurance (QA) Meeting, the Medical Director will be asked to consider a list of Standing Lab Orders that can be kept so that closer monitoring can be done. The supervising RN will be the person in charge of this monitoring at this time. On 11/18/10 at 12:20 the facility's administrator was informed that the IJ had been lowered to actual harm at a pattern that is not immediate jeopardy, because the facility had not yet in serviced all staff, implemented or evaluated their corrective action.

Based on observation, interviews and record review it was determined that for 1 of 16 sampled residents (Resident #1) the facility failed to implement policies and procedures that prohibit neglect when the facility failed to A.) prohibit neglect for one resident with a history of falls; rendering her at risk for serious injury from falls. The facility failed to develop intervention strategies to prevent falls, monitor for changes that could contribute to Falls (Medications: [MEDICATION NAME] for treatment of [REDACTED]. A.) Resident #1 had a history of [REDACTED]. Following each fall the facility neglected to thoroughly reassess after the fall to determine causal factors to develop preventive interventions to prevent falls. Resident #1 was sent to the hospital on [DATE] with altered mental status and it was documented she had a fall on this date also. On arrival to the emergency room it was discovered she had [MEDICATION NAME] (anti-convulsant) toxicity (high level of [MEDICATION NAME]). There was no laboratory test conducted from her admission to the facility on [DATE] to 08/22/10; although she had been on [MEDICATION NAME] medication for a history of [MEDICAL CONDITION]. The facility neglected to obtain resident labs; monitor the [MEDICATION NAME] levels that could contribute to falls. Following Resident #1's falls the facility failed to monitor for changes that could contribute to the falls (Medication [MEDICATION NAME] for treatment of [REDACTED]. Resident # 1's [MEDICATION NAME] levels remaining subtheraputic after this hospitalization . Resident # 1 fell on [DATE] in her room, complained of left hip, leg, elbow and shoulder pain and was transferred to the emergency room . She returned to the facility on [DATE] and the facility failed to obtain accurate emergency room [DIAGNOSES REDACTED]. Staff documented in the nurses notes Resident #1 had a left elbow fracture. Hospital records obtained by the surveyor on 11/16/10 revealed Resident #1 was diagnosed with [REDACTED]. The staff failed to identify and assess the pubic bone fracture or the concussion until 11/16/10. Resident #1 continues to complain of left leg and knee pain. With her Activity of Daily Living (ADL) levels having decreased due to the fall/injury of 11/01/10. Resident #1 was independent of most of her ADL's prior to the fall of 11/01/10 and now needs assistance with toileting and standing related to pain in the left leg and knee area. A.) An Immediate Jeopardy (IJ) was identified on 11/16/10 at 1:10 PM. While the IJ was lowered to a non-Immediate Jeopardy on 11/17/10 at 5:27 AM, the facility remained out of compliance at a pattern of Actual Harm because the facility had not yet in serviced all staff, implemented or evaluated their corrective action. B.) On 11/11/10 Acting Director of Nursing (Acting DON), Social Worker, and Facility Coordinator tried to convince Resident #13 "she was unhappy" and the facility could not meet her needs. On 10/29/10 the facility Owner humiliated Resident #13 in front of her family member and facility staff by yelling at her outside of the facility because Resident #13 was talking with a terminated employee. On 10/07/10 the facility Owner told Resident #13 he could not trust her and she and her father would have to leave the facility after she spoke with a State Surveyor. Each incident caused mental anguish, humiliation, disruption of sleep, crying and voluntary isolation of Resident #13 resulting in her voluntary discharged from the facility. The facility's failure to ensure residents are free from verbal abuse and mental abuse has the potential to affect the mental status of the 78 residents of the facility. B.) An IJ was identified on 11/11/10 at 3:30 PM for failure to ensure Resident #13 was free from harassment by facility staff which resulted in psychological harm. While the IJ was removed on 11/11/10 at 10:20 PM after the plan of removal was accepted, the facility remained out of compliance at a level of potential for more than minimum harm at a pattern because all staff had not been trained on abuse and neglect policy and procedures. Seventy-eight residents could be affected by the deficient practices. The facility deficient practice could place any of the 78 residents in the facility that depend on nursing staff for accurate and timely assessments at risk for delay in or inappropriate medical treatment as well as abuse/neglect. Findings include: Review of the facility medical record for Resident #1 documented she was admitted on [DATE] with the Physician order [REDACTED]. Review of the Nurses Notes dated 04/25/10 revealed Resident #1 had a [MEDICAL CONDITION]. This was the last [MEDICAL CONDITION] documented in the nurse's notes. An Observation and interview on 11/15/10 at 2:20 PM Resident #1 appeared to be confused and drowsy. She was sitting in her wheelchair with her eyes closed, her chin on her chest and she spoke in a low voice during the interview. Surveyor checked the wheelchair and noted even when locked the wheels continued to move. Resident #1 stated she did not know what happened the day of the fall; she stated she just fell . Resident #1 stated she stills does not feel well; her leg and knee continues to hurt. Review of the accident/incident reports dated 11/01/10, 10/15/10, 09/19/10, 08/30/10, and 08/22/10 identified falls that occurred for Resident #1. Review of the Incident/Accident report dated 08/22/10 had documentation Resident #1 "fell while attempting to sit in the wheelchair when the wheelchair moved". Review of the nurses notes dated 08/21/10 late entry, Resident #1 " very sleepy all the time, is more Confused than usual also complained of right flank area discomfort " . Review of the Nurses Notes dated 08/22/10 had documentation that Resident #1 "fell at 0520 while attempting to change clothes and went to sit in the wheelchair with the wheels not locked and the chair rolled". The nurse ' s notes for 6AM/6PM had documentation that Resident #1 " was very sleepy and is more confused than usual " . Documentation at "1830 resident tearful shivering and confused. Family requested transfer to the hospital related to change of mental status". She was transferred by ambulance on 08/22/10 at 1915. Resident #1 was admitted to the hospital with [REDACTED]. The facility neglected to obtain resident labs; monitor the [MEDICATION NAME] levels that could contribute to falls. Following Resident #1's fall on 08/22/10 the facility failed to monitor for changes that could contribute to the falls (Medication [MEDICATION NAME] for treatment of [REDACTED]. Resident #1 was hospitalized returning to the facility on [DATE]. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. There was a [MEDICATION NAME] level ordered for 09/03/10 but not drawn until 09/17/10 which was 8.53 (below the normal). There was no evidence that the [MEDICATION NAME] medication given to prevent [MEDICAL CONDITION] were monitored or reviewed to determine if this was the possible cause of the resident ' s falls. Resident # 1's [MEDICATION NAME] levels remaining subtheraputic after this hospitalization . Review of the Incident/Accident report dated 08/30/10 documented Resident #1 "resident stated she went to the bathroom and walking back " falling to be "found lying on floor on right side". With this second fall the care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Review of the Incident/Accident report dated 09/19/10 Resident #1 fell (third fall) trying to get from her wheelchair to her bed. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Review of the Incident/Accident report dated 10/15/10 Resident #1 fell (fourth fall) while getting out of bed and going to the bathroom. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Only intervention was documented on the incident report "encourage resident to use call light for future super visional assistance with transfers". Resident # 1 fell (fifth fall) on 11/01/10 in her room, complained of left hip, leg, elbow and shoulder pain and was transferred to the emergency room . She returned to the facility on [DATE] and the facility failed to obtain accurate emergency room [DIAGNOSES REDACTED]. Staff documented in the nurses notes Resident #1 had a left elbow fracture. Hospital records obtained by the surveyor on 11/16/10 revealed Resident #1 was diagnosed with [REDACTED]. The staff failed to identify and assess the pubic bone fracture or the concussion until 11/16/10. Resident #1 continues to complain of left leg and knee pain. With her Activity of Daily Living (ADL) levels having decreased due to the fall/injury of 11/01/10. Resident #1 was independent of most of her ADL's prior to the fall of 11/01/10 and now needs assistance with toileting and standing related to pain in the left leg and knee area. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. There was no evidence that the [MEDICATION NAME] medication given to prevent [MEDICAL CONDITION] were monitored or reviewed for possible cause of the falls. In an interview on 11/15/10 at 3:15 PM CNA X and CNA Y stated Resident #1 was basically independent before the last fall. Now she needs assist to do activities of daily living. In an interview on 11/16/10 at 9:40 AM the Director of Nurses of the nursing home stated she was not aware of fall preventive measures in place for Resident #1 and the facility does not have a fall committee to address falls. She stated she had only been in the Director of Nurses position 3 weeks but was the Registered Nurses on East hall for 2 ? years. She was not aware of specific fall prevention measure used in the facility other than chair alarms and low beds. The DON further stated that fall risk assessments are to be completed quarterly and she did not know why Resident #1 had not had one done since 4/10. She stated she did not know about the care plan Review of the medical record on 11/16/10 for Resident #1 revealed the only fall risk assessment was completed on 04/10 upon admission and no other fall risk assessment was completed until 11/15/10 following surveyor ' s prompting. The 11/15/10 fall risk assessment scored Resident #1 at 15 which is high risk for falls. (A score of 10 or above represents high risks). Review of the quarterly undated and unsigned Minimum (MDS) data set [DATE] identifies a fall in the last 31-180 days. Review of the care plan dated 09/27/10 did not address the history of falls or fall preventive measures. There was a care plan addressing [MEDICAL CONDITION] which did not address the potential for falls. In an interview on 11/17/10 at 4:00 PM the Minimum Data Set (MDS) nurses stated they were updating MDS's and care plans. They stated the MDS ' s and care plans were behind as people have left and new staff was hired. Review of a undated facility "policy and procedure for Incident/Accidents Reports" provided by the ADON documented that a resident would be assessed for 72 hours after an incident and documentation would include the disposition with the date, resident ' s condition and the nurse's signature and put in the Director of Nurses door. The policy and procedure does not address fall preventive measures the facility can use. In an interview on 11/16/10 at 1:00 PM the attending physician for Resident #1 stated his expectations would include the staff to monitor for at least 72 hours after Resident #1 returned to the facility from the emergency room . He stated he felt that Resident #1 may be having petit mal [MEDICAL CONDITION] (minor [MEDICAL CONDITION]) because of the amount of falls she has had and that her [MEDICATION NAME] (anti-convulsant) is at subtherapeutic levels which could contribute to her falls. On 11/16/10 at 1:15 PM the facility's acting Administrator was informed that an Immediate Jeopardy existed due to the facility's failure to implement policies and procedures that prohibit neglect when the facility failed to prohibit neglect for one resident with a history of falls; rendering her at risk for serious injury from falls. The facility failed to develop intervention strategies to prevent falls, monitor for changes that could contribute to Falls (Medications: [MEDICATION NAME] for treatment of [REDACTED]. On 11/17/07 at 5:27 AM the facility provided surveyors with a written plan of removal which reflected the following: Failure to Prevent Neglect B1 and B4: The Director of Nurses and Assistant Director of Nurses or supervising RN will be notified of any injury to a resident as soon as possible after the charge nurse has assessed and evaluated the resident for any injury. This notification will be provided on a form that will be created and in place no later than December 1, 2010. This form will be kept in a binder in the Assistant Director of Nurses office. The following are the procedures that will be initiated as soon as the resident is stabilized. a. The physician is to be notified immediately of orders to treat any type of change of condition. b. The charge nurse will assess, notify and treat as the physician orders. c. The charge nurse will notify the MD and residents family of the incident. ? Assess the resident and document notification of the family and MD in the clinical record. ? Submit incident reports to the Administrator and Supervisor RN daily to determine need for further investigation. d. Following any falls, the resident will be referred to Physical Therapy (PT) for screening, evaluation, treatment and recommendations. ? MD will be notified of all injures and informed on signs and symptoms presented and orders received will be initiated and followed prescribed. ? Interdisciplinary Team (IDT) will meet to discuss appropriate interventions. ? IDT will review and revise Care Plan. e. A Fall Committee will be created to review all accidents and injuries weekly. Review, discuss and document conclusions and preventive measures. ? Based on Incident/Accident Report and MD orders, the nurses will evaluate. Assess, and document injuries or issues until resoled on each shift. Any unusual signs or symptoms may be addressed at this time. f. Nursing Staff will be in-serviced by Assistant Director of Nurses (ADON) beginning Thursday, November 18, 2010 and will be ongoing as necessary. The subjects will cover different systems that will include, but not limited to, Chart Audits, Lab Audits, Correcting Documentation errors, Prevent of Med Errors, Assessing resident change of conditions, Interpreting signs and symptoms of declining resident conditions, what to call into the Primary Care Physician (PCP) and what can be faxed to the PCP and other topics yet to be decided. ? The Nurse Aide ' s (CNA ' s) will be in-serviced on what to report to the charge nurse and when it needs to be reported, some things will need to be reported. B3 a. The charge nurses will receive new orders and will order meds, transcribe new orders onto the appropriate Medication and Treatment sheets and other forms as dictated by the order. b. The charge nurse will ensure Responsible Party is notified of new orders. c. The night shift charge nurses will audit the clinical records and MD orders to verify the orders are transcribed and documented properly on the related forms. Red ink will be used to indicate appropriate transcription. d. All current staff will be in-serviced starting on November 18, 2010 and completed by November 22, 2010. In-service will be conducted by the ADON on proper techniques for auditing, transcription and documentation entries of MD orders. All new hires will be orientated to the new Policies and Procedures. e. Any medication error reports will be completed as indicated and the person making the error will be counseled with further disciplinary action for repeat offenses or very serious errors that might jeopardize a residents well being. f. The charge nurse will notify and document in the clinical record that the family has been informed of any change of medication or treatment regime. B 11 a. Residents that have changes of condition will be assessed by the charge nurse. The charge nurse will notify the MD for treatment orders immediately after change of condition has been identified. b. Any changes in condition will be discussed in the daily stand-up meeting and interventions will be decided at this time. The supervising RN will be responsible for monitoring quality of care for all residents. Failure to protect from undue adverse medication consequences and /or failure to provide medications as prescribed. D 4 c. Staff will continue to be in-serviced on the dangers of medication errors and the effects of not administering medications as ordered and prescribed by a physician. These in-services will be presented by the ADON weekly beginning Thursday, November 18. 2010 and completed by November 22, 2010. d. This in-service training will be for the Medication Aides and the Nurses on a regular basis as appropriate. e. This training will include the ' 6 ' Rights of Medication Administration which includes documentation. This will ensure that staff is familiar and comfortable with this protocol. f. If a medication error occurs the Physician, Medical Director and the resident ' s Responsible Party will be notified. A medication error report will be initiated and the Policy and Procedure will be followed. g. The Medical Director will approve all Resident Care Policy and Procedures. h. Facility will request the Pharmacy Consultant to complete a medication audit as soon as possible and then at regular intervals thereafter. i. A Policy and Procedure will be put into place to address medication errors, the consequences and the effects on the elderly. j. Any newly adopted Policy and Procedure (P & P) will be approved by the Medical Director. k. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]., will be printed a the least 8 days prior to the last day of the month for corrections as needed and double checking against the telephone orders and consolidated physician orders. l. All consolidated physician orders [REDACTED]. The Supervising RN or designee will be responsible to oversee that this is completed and correct. D 6 Many medications that residents receive must be monitored for appropriate levels in the blood to maintain adequate effectiveness. The PDR dictates what medications must be titrated and these labs must be done for each different medication on a regular schedule to ensure the effectiveness of the medication. The Labs for these medications are ordered by the physician and the physician must receive these labs in a timely manner. a. The Charge Nurse will receive the lab order, complete the Lab Requisition Form with all of the required information and place in the Lab Draw Book. b. Notification of the Physician will be based on lab results conveyed. Critical labs require immediate notification and response of the Physician for appropriate action. Appropriate documentation will be made in the clinical record by the Charge Nurse. c. A list of drugs that require titration will be requested from the pharmacy consultant and this list will be kept in the Lab Craw Book and a copy will be placed in the front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] d. During the Quality Assurance (QA) Meeting, the Medical Director will be asked to consider a list of Standing Lab Orders that can be kept so that closer monitoring can be done. The supervising RN will be the person in charge of this monitoring at this time. On 11/18/10 at 12:20 the facility's administrator was informed that the IJ had been lowered to actual harm at a pattern that is not immediate jeopardy, because the facility had not yet in serviced all staff, implemented or evaluated their corrective action. On 11/11/10 at 3:52 PM the IJ was announced to the Owner of the facility who state, " We have been dealing with this for six months ...What happens to her, we still don't want her here?" In an interview on 11/16/10 at 7:15 PM Resident # 17 stated she went to the office the other day and the Owner ask her how it was going and she told him everyone is upset as they are only to have meat with breakfast two days a week now. She reported the Owner told her " thats what the state says and if you don't like it you can gp somewhere else". Resident #17 stated this was "offensive" for him to talk to me this way. She further said it was upsetting what happen to Resident # 13 and how the facility treated her. She stated "it is our fault as Resident #13 was our president and we wquld tell her our concern...then she got in trouble for them". The Plan of Removal as submitted by the facility was as follows: 1) Shift by shift in-service training with all staff, all disciplines regarding prevention of Abuse specifically regarding psychological harm and also focusing on "good" customer service approaches to handle concerns (complaints) voiced by residents. These in-services will be documented for content and attendance and will continue for next three full days to insure maximum number of staff is exposed to the in-service. a. At this training, Abuse Prohibition policies will be reviewed. b. Focus on techniques for staff response to concerns/complaints voiced by residents or others in facility. c. Review grievance/concern process. d. Remind that ALL verbal concerns/complaints be documented on the Grievance/Concern Intake form and follow-up documented and conveyed to the resident/family member/staff involved. e. Review Resident Rights regarding Transfers and Discharges, who can make that decision, and content of such notices, including right to appeal and advocacy opportunities. f. Strategies for dealing with burn-out and "difficult" situations. g. This material will be incorporated into all "new hire" orientation packets and all "new hires" will be required to complete this training prior to first shift in facility. h. Facility will utilize Consultant, in a consultant role to train Facility Coordinator, in a train-the-trainer mode to teach this material to all new hires. Updates will be on-going as identified by the facility and the QAA process. 2) General in-service training with all staff on next payroll date, 11/12/2010, 2:00 PM with emphasis on approaches to deal with concerns voiced by resident as noted above. a. Review of staff responsibilities and review of "eviction" process and who can initiate and what valid reasons exist. b. Review of facility policy regarding "evictions." c. Review of who gets to decide if we can "meet the resident's needs" i. Resident/family input ii. Clearly documented medical issues requiring transfer iii. Assessment of needs and ability to provide for these needs 3) Special called Resident Council meeting on Friday, November 12, 2010 at 10:30 AM to discuss grievance/concern process and to (re)assure residents that staff are here to serve them and to assist in making Facility as pleasant a place to live as possible. Staff will encourage residents to voice any anxieties or concerns so that staff may provide interventions as appropriate, including professional services as indicated. 4) Letter to all families outlining Facility Policy for Raising and Addressing Concerns with copy included in letter. a. Include a letter invitation to next Family Council meeting where this topic will be included on the agenda. b. This letter will be mailed on Friday, November 12, 2010, to the persons identified as either Responsible party or first next of kin in the clinical record of all current residents. An invitation will also be mailed to the local ombudsman and the medical director at this time. c. Next Family Council meeting will be scheduled for Monday, December 5, 2010 at 7:00 PM. The meeting will be held in the facility dining room. d. Invite families to ask questions and voice concerns in the letter. e. Contract professional for psychological intervention. Contractor with an Advanced Nurse Practitioner in Psychiatry. f. Contracted services are provided weekly and may include group services if such need is identified. g. Contract with Contractor (or other similar professional) to provide concerns in a professional and appropriate manner to prevent concerns in a professional, appropriate manner to prevent psychological harm. This training to be provided as soon as can be arranged and no later than 13 days from this date, or no later than November 24, 2010. h. Advise of availability of Ombudsman and provide contact numbers in letter. 5) Regarding discharges of residents to another facility, Oaks will provide: a. All information necessary to receiving facility to ensure continuity of care will be provided by Facility upon request. b. Facility Social Worker will place follow-up call to Social Worker at receiving facility to establish professional relationship and facilitate transfer of any information requested. c. HIPAA and other protections will be observed for the protection of Resident #13, as well as for all residents of the Facility. 6) Facility will forward attached letter to Resident #13, including information on providing records to facilitate continuity of care. 7) The QAA committee will review this process and ensure that all components are being followed to ensure no resident receives any psychological harm. a. The Administrator will bring Concern/Grievance book to each QAA committee meeting and will review concerns and responses. b. The QAA committee will recommend Action Plans be developed where ongoing or targeted issues need to be addressed. The Action Plans will include specific target dates for completion with individual accountability identified. c. The QAA committee will ensure the involvement and advice of the Medical Director on review of Concerns/Grievances. d. The QAA committee will meet quarterly with the date and time published at least two weeks in advance and specific invitations delivered by mail or fax to QAA committee members, as identified in the QAA policy. e. The next QAA meeting will be scheduled for Wednesday, December 1, 2010 at 1:00 PM to establish a new quarterly pattern and for the purpose of including the newly hired Administrator. While the IJ for Resident #1 was lowered to a non-Immediate Jeopardy on 11/17/10 at 5:27 AM, the facility remained out of compliance at a pattern of Actual Harm because the facility had not yet in serviced all staff, implemented or evaluated their corrective action. While the IJ was removed on 11/11/10 at 10:20 PM after the plan of removal was accepted, the facility remained out of compliance at a level of potential for more than minimum harm at a pattern because all staff had not been trained on abuse and neglect policy and procedures. Seventy-eight residents could be affected by the deficient practices.

Based on observation, interviews and record review it was determined that for 1 of 16 sampled residents (Resident #1) the facility failed to implement policies and procedures that prohibit neglect when the facility failed to prohibit neglect for one resident with a history of falls; rendering her at risk for serious injury from falls. The facility failed to develop intervention strategies to prevent falls, monitor for changes that could contribute to Falls (Medications: [MEDICATION NAME] for treatment of [REDACTED]. Resident #1 had a history of [REDACTED]. Following each fall the facility neglected to thoroughly reassess after the fall to determine causal factors to develop preventive interventions to prevent falls. Resident #1 was sent to the hospital on [DATE] with altered mental status and it was documented she had a fall on this date also. On arrival to the emergency room it was discovered she had [MEDICATION NAME] (anti-convulsant) toxicity (high level of [MEDICATION NAME]). There was no laboratory test conducted from her admission to the facility on [DATE] to 08/22/10; although she had been on [MEDICATION NAME] medication for a history of [MEDICAL CONDITION]. The facility neglected to obtain resident labs; monitor the [MEDICATION NAME] levels that could contribute to falls. Following Resident #1's falls the facility failed to monitor for changes that could contribute to the falls (Medication [MEDICATION NAME] for treatment of [REDACTED]. Resident # 1's [MEDICATION NAME] levels remaining subtheraputic after this hospitalization . Resident # 1 fell on [DATE] in her room, complained of left hip, leg, elbow and shoulder pain and was transferred to the emergency room . She returned to the facility on [DATE] and the facility failed to obtain accurate emergency room [DIAGNOSES REDACTED]. Staff documented in the nurses notes Resident #1 had a left elbow fracture. Hospital records obtained by the surveyor on 11/16/10 revealed Resident #1 was diagnosed with [REDACTED]. The staff failed to identify and assess the pubic bone fracture or the concussion until 11/16/10. Resident #1 continues to complain of left leg and knee pain. With her Activity of Daily Living (ADL) levels having decreased due to the fall/injury of 11/01/10. Resident #1 was independent of most of her ADL's prior to the fall of 11/01/10 and now needs assistance with toileting and standing related to pain in the left leg and knee area. An Immediate Jeopardy (IJ) was identified on 11/16/10 at 1:10 PM. While the IJ was lowered to a non-immediate Jeopardy on 11/17/10 at 5:27 AM, the facility remained out of compliance at a pattern of Actual Harm because the facility had not yet in serviced all staff, implemented or evaluated their corrective action. The facility deficient practice could place any of the 78 residents in the facility that depend on nursing staff for accurate and timely assessments at risk for delay in or inappropriate medical treatment. Findings include: Review of the facility medical record for Resident #1 documented she was admitted on [DATE] with the Physician order [REDACTED]. Review of the Nurses Notes dated 04/25/10 revealed Resident #1 had a [MEDICAL CONDITION]. This was the last [MEDICAL CONDITION] documented in the nurse's notes. An Observation and interview on 11/15/10 at 2:20 PM Resident #1 appeared to be confused and drowsy. She was sitting in her wheelchair with her eyes closed, her chin on her chest and she spoke in a low voice during the interview. Surveyor checked the wheelchair and noted even when locked the wheels continued to move. Resident #1 stated she did not know what happened the day of the fall; she stated she just fell . Resident #1 stated she stills does not feel well; her leg and knee continues to hurt. Review of the accident/incident reports dated 11/01/10, 10/15/10, 09/19/10, 08/30/10, and 08/22/10 identified falls that occurred for Resident #1. Review of the Incident/Accident report dated 08/22/10 had documentation Resident #1 "fell while attempting to sit in the wheelchair when the wheelchair moved". Review of the nurses notes dated 08/21/10 late entry, Resident #1 " very sleepy all the time, is more Confused than usual also complained of right flank area discomfort " . Review of the Nurses Notes dated 08/22/10 had documentation that Resident #1 "fell at 0520 while attempting to change clothes and went to sit in the wheelchair with the wheels not locked and the chair rolled". The nurse ' s notes for 6AM/6PM had documentation that Resident #1 " was very sleepy and is more confused than usual " . Documentation at "1830 resident tearful shivering and confused. Family requested transfer to the hospital related to change of mental status". She was transferred by ambulance on 08/22/10 at 1915. Resident #1 was admitted to the hospital with [REDACTED]. The facility neglected to obtain resident labs; monitor the [MEDICATION NAME] levels that could contribute to falls. Following Resident #1's fall on 08/22/10 the facility failed to monitor for changes that could contribute to the falls (Medication [MEDICATION NAME] for treatment of [REDACTED]. Resident #1 was hospitalized returning to the facility on [DATE]. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. There was a [MEDICATION NAME] level ordered for 09/03/10 but not drawn until 09/17/10 which was 8.53 (below the normal). There was no evidence that the [MEDICATION NAME] medication given to prevent [MEDICAL CONDITION] were monitored or reviewed to determine if this was the possible cause of the resident ' s falls. Resident # 1's [MEDICATION NAME] levels remaining subtheraputic after this hospitalization . Review of the Incident/Accident report dated 08/30/10 documented Resident #1 "resident stated she went to the bathroom and walking back " falling to be "found lying on floor on right side". With this second fall the care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Review of the Incident/Accident report dated 09/19/10 Resident #1 fell (third fall) trying to get from her wheelchair to her bed. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Review of the Incident/Accident report dated 10/15/10 Resident #1 fell (fourth fall) while getting out of bed and going to the bathroom. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. Only intervention was documented on the incident report "encourage resident to use call light for future super visional assistance with transfers". Resident # 1 fell (fifth fall) on 11/01/10 in her room, complained of left hip, leg, elbow and shoulder pain and was transferred to the emergency room . She returned to the facility on [DATE] and the facility failed to obtain accurate emergency room [DIAGNOSES REDACTED]. Staff documented in the nurses notes Resident #1 had a left elbow fracture. Hospital records obtained by the surveyor on 11/16/10 revealed Resident #1 was diagnosed with [REDACTED]. The staff failed to identify and assess the pubic bone fracture or the concussion until 11/16/10. Resident #1 continues to complain of left leg and knee pain. With her Activity of Daily Living (ADL) levels having decreased due to the fall/injury of 11/01/10. Resident #1 was independent of most of her ADL's prior to the fall of 11/01/10 and now needs assistance with toileting and standing related to pain in the left leg and knee area. The care plan did not reflect falls as a problem, nor was it updated after this fall and no preventive measures for falls were addressed. The fall risk assessment (last done on admission 04/10) was not updated or re-evaluated. The resident had a history of [REDACTED]. There was no evidence that the [MEDICATION NAME] medication given to prevent [MEDICAL CONDITION] were monitored or reviewed for possible cause of the falls. In an interview on 11/15/10 at 3:15 PM CNA X and CNA Y stated Resident #1 was basically independent before the last fall. Now she needs assist to do activities of daily living. In an interview on 11/16/10 at 9:40 AM the Director of Nurses of the nursing home stated she was not aware of fall preventive measures in place for Resident #1 and the facility does not have a fall committee to address falls. She stated she had only been in the Director of Nurses position 3 weeks but was the Registered Nurses on East hall for 2 ? years. She was not aware of specific fall prevention measure used in the facility other than chair alarms and low beds. The DON further stated that fall risk assessments are to be completed quarterly and she did not know why Resident #1 had not had one done since 4/10. She stated she did not know about the care plan Review of the medical record on 11/16/10 for Resident #1 revealed the only fall risk assessment was completed on 04/10 upon admission and no other fall risk assessment was completed until 11/15/10 following surveyor ' s prompting. The 11/15/10 fall risk assessment scored Resident #1 at 15 which is high risk for falls. (A score of 10 or above represents high risks). Review of the quarterly undated and unsigned Minimum (MDS) data set [DATE] identifies a fall in the last 31-180 days. Review of the care plan dated 09/27/10 did not address the history of falls or fall preventive measures. There was a care plan addressing [MEDICAL CONDITION] which did not address the potential for falls. In an interview on 11/17/10 at 4:00 PM the Minimum Data Set (MDS) nurses stated they were updating MDS's and care plans. They stated the MDS ' s and care plans were behind as people have left and new staff was hired. Review of a undated facility "policy and procedure for Incident/Accidents Reports" provided by the ADON documented that a resident would be assessed for 72 hours after an incident and documentation would include the disposition with the date, resident ' s condition and the nurse's signature and put in the Director of Nurses door. The policy and procedure does not address fall preventive measures the facility can use. In an interview on 11/16/10 at 1:00 PM the attending physician for Resident #1 stated his expectations would include the staff to monitor for at least 72 hours after Resident #1 returned to the facility from the emergency room . He stated he felt that Resident #1 may be having petit mal [MEDICAL CONDITION] (minor [MEDICAL CONDITION]) because of the amount of falls she has had and that her [MEDICATION NAME] (anti-convulsant) is at subtherapeutic levels which could contribute to her falls. On 11/16/10 at 1:15 PM the facility's acting Administrator was informed that an Immediate Jeopardy existed due to the facility's failure to implement policies and procedures that prohibit neglect when the facility failed to prohibit neglect for one resident with a history of falls; rendering her at risk for serious injury from falls. The facility failed to develop intervention strategies to prevent falls, monitor for changes that could contribute to Falls (Medications: [MEDICATION NAME] for treatment of [REDACTED]. On 11/17/07 at 5:27 AM the facility provided surveyors with a written plan of removal which reflected the following: Failure to Prevent Neglect B1 and B4: The Director of Nurses and Assistant Director of Nurses or supervising RN will be notified of any injury to a resident as soon as possible after the charge nurse has assessed and evaluated the resident for any injury. This notification will be provided on a form that will be created and in place no later than December 1, 2010. This form will be kept in a binder in the Assistant Director of Nurses office. The following are the procedures that will be initiated as soon as the resident is stabilized. a. The physician is to be notified immediately of orders to treat any type of change of condition. b. The charge nurse will assess, notify and treat as the physician orders. c. The charge nurse will notify the MD and residents family of the incident. ? Assess the resident and document notification of the family and MD in the clinical record. ? Submit incident reports to the Administrator and Supervisor RN daily to determine need for further investigation. d. Following any falls, the resident will be referred to Physical Therapy (PT) for screening, evaluation, treatment and recommendations. ? MD will be notified of all injures and informed on signs and symptoms presented and orders received will be initiated and followed prescribed. ? Interdisciplinary Team (IDT) will meet to discuss appropriate interventions. ? IDT will review and revise Care Plan. e. A Fall Committee will be created to review all accidents and injuries weekly. Review, discuss and document conclusions and preventive measures. ? Based on Incident/Accident Report and MD orders, the nurses will evaluate. Assess, and document injuries or issues until resoled on each shift. Any unusual signs or symptoms may be addressed at this time. f. Nursing Staff will be in-serviced by Assistant Director of Nurses (ADON) beginning Thursday, November 18, 2010 and will be ongoing as necessary. The subjects will cover different systems that will include, but not limited to, Chart Audits, Lab Audits, Correcting Documentation errors, Prevent of Med Errors, Assessing resident change of conditions, Interpreting signs and symptoms of declining resident conditions, what to call into the Primary Care Physician (PCP) and what can be faxed to the PCP and other topics yet to be decided. ? The Nurse Aide ' s (CNA ' s) will be in-serviced on what to report to the charge nurse and when it needs to be reported, some things will need to be reported. B3 a. The charge nurses will receive new orders and will order meds, transcribe new orders onto the appropriate Medication and Treatment sheets and other forms as dictated by the order. b. The charge nurse will ensure Responsible Party is notified of new orders. c. The night shift charge nurses will audit the clinical records and MD orders to verify the orders are transcribed and documented properly on the related forms. Red ink will be used to indicate appropriate transcription. d. All current staff will be in-serviced starting on November 18, 2010 and completed by November 22, 2010. In-service will be conducted by the ADON on proper techniques for auditing, transcription and documentation entries of MD orders. All new hires will be orientated to the new Policies and Procedures. e. Any medication error reports will be completed as indicated and the person making the error will be counseled with further disciplinary action for repeat offenses or very serious errors that might jeopardize a residents well being. f. The charge nurse will notify and document in the clinical record that the family has been informed of any change of medication or treatment regime. B 11 a. Residents that have changes of condition will be assessed by the charge nurse. The charge nurse will notify the MD for treatment orders immediately after change of condition has been identified. b. Any changes in condition will be discussed in the daily stand-up meeting and interventions will be decided at this time. The supervising RN will be responsible for monitoring quality of care for all residents. Failure to protect from undue adverse medication consequences and /or failure to provide medications as prescribed. D 4 c. Staff will continue to be in-serviced on the dangers of medication errors and the effects of not administering medications as ordered and prescribed by a physician. These in-services will be presented by the ADON weekly beginning Thursday, November 18. 2010 and completed by November 22, 2010. d. This in-service training will be for the Medication Aides and the Nurses on a regular basis as appropriate. e. This training will include the ' 6 ' Rights of Medication Administration which includes documentation. This will ensure that staff is familiar and comfortable with this protocol. f. If a medication error occurs the Physician, Medical Director and the resident ' s Responsible Party will be notified. A medication error report will be initiated and the Policy and Procedure will be followed. g. The Medical Director will approve all Resident Care Policy and Procedures. h. Facility will request the Pharmacy Consultant to complete a medication audit as soon as possible and then at regular intervals thereafter. i. A Policy and Procedure will be put into place to address medication errors, the consequences and the effects on the elderly. j. Any newly adopted Policy and Procedure (P & P) will be approved by the Medical Director. k. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]., will be printed a the least 8 days prior to the last day of the month for corrections as needed and double checking against the telephone orders and consolidated physician orders. l. All consolidated physician orders [REDACTED]. The Supervising RN or designee will be responsible to oversee that this is completed and correct. D 6 Many medications that residents receive must be monitored for appropriate levels in the blood to maintain adequate effectiveness. The PDR dictates what medications must be titrated and these labs must be done for each different medication on a regular schedule to ensure the effectiveness of the medication. The Labs for these medications are ordered by the physician and the physician must receive these labs in a timely manner. a. The Charge Nurse will receive the lab order, complete the Lab Requisition Form with all of the required information and place in the Lab Draw Book. b. Notification of the Physician will be based on lab results conveyed. Critical labs require immediate notification and response of the Physician for appropriate action. Appropriate documentation will be made in the clinical record by the Charge Nurse. c. A list of drugs that require titration will be requested from the pharmacy consultant and this list will be kept in the Lab Craw Book and a copy will be placed in the front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] d. During the Quality Assurance (QA) Meeting, the Medical Director will be asked to consider a list of Standing Lab Orders that can be kept so that closer monitoring can be done. The supervising RN will be the person in charge of this monitoring at this time. On 11/18/10 at 12:20 the facility's administrator was informed that the IJ had been lowered to actual harm at a pattern that is not immediate jeopardy, because the facility had not yet in serviced all staff, implemented or evaluated their corrective action.

Based on observation, interview and record review the facility failed to ensure residents were free from verbal and mental abuse when 1 of 16 sampled residents (Resident #13) was verbally and mentally abused by 4 of 4 facility staff due to voicing concerns and grievances, causing the resident fear of retaliation, as well as humiliation, mental anguish and increased depression if she did not voluntarily discharge from the facility. On 11/11/10 Resident #13 voluntarily discharged herself from the facility because of the staff treatment and these fears. She further was concern the facility would retaliate against her and not allow her to visit her father who remained a resident at the facility. Resident #1 had been told that terminated staff could not visit anyone at the facility. A) On 11/11/10 Acting Director of Nursing (Acting DON), Social Worker, and Facility Coordinator tried to convince Resident #13 "she was unhappy" and the facility could not meet her needs. B) On 10/29/10 the facility Owner humiliated Resident #13 in front of her family member and facility staff by yelling at her outside of the facility because Resident #13 was talking with a terminated employee. C) On 10/07/10 the facility Owner told Resident #13 he could not trust her and she and her father would have to leave the facility after she spoke with a State Surveyor. Each incident caused mental anguish, humiliation, disruption of sleep, crying and voluntary isolation of Resident #13 resulting in her voluntary discharged from the facility. The facility's failure to ensure residents are free from verbal abuse and mental abuse has the potential to affect the mental status of the 78 residents of the facility. An IJ was identified on 11/11/10 at 3:30 PM for failure to ensure Resident #13 was free from harassment by facility staff which resulted in psychological harm. While the IJ was removed on 11/11/10 at 10:20 PM after the plan of removal was accepted, the facility remained out of compliance at a level of potential for more than minimum harm at a pattern because all staff had not been trained on abuse and neglect policy and procedures. Seventy-eight residents could be affected by the deficient practices. Findings include: Review of Resident #13's clinical record revealed Resident #13 was admitted to the facility on [DATE] after a three-day hospitalization . Resident #13 reported multiple hospitalization s caused by her inability to care for herself. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. Review of an unsigned Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #13 ' s unsigned Minimum (MDS) data set [DATE], she requires " extensive assistance " with bed mobility, walking, dressing, toileting and bathing, incontinent of bowel and bladder, wears incontinent brief, history of falls, abrasion/bruises, skin tears, surgical wounds and foot problems. Her cognitive skill for daily decision-making is modified independence with an improved change in cognitive status. She requires 22 medications. Overall self sufficiency indicates a significant deterioration requiring more support. No behavioral symptoms were indicated and the comparison to status 90 days prior is improved. Record review of Resident #13 ' s most recent Care Plan dated 6/14/10 indicates care planning for depression. Further review of the facility record found no documentation or care planning for any behavioral symptoms. Review of Resident #13's clinical record did not reveal documentation of any needs the facility could not meet. In an interview on 11/10/10 at 9:50 AM the Acting Administrator stated he was upset with the President of Resident Council (Resident #13) over writing a complaint against him for using the resident's fork to taste the resident's eggs and placed the fork back on her plate. Acting Administrator stated Resident #13 "documents everything, and complains all the time". He further stated, "She is the reason why he would not take the job as Administrator at this facility full time." He further stated he tasted her eggs as she had complained about them. In an interview on 11/10/10 at 10:00 AM the Acting Administrator and the facility Owner presented a 5-page letter dated 08/24/10 from Resident #13 as President of the Resident Council to the Owner outlining requested changes in the Facility. At this time, the facility Owner asked the survey team if he could give Resident #13 a 30-day notice to move because Resident #13 "complained all the time." During an interview on 11/10/10 at 10:50 AM Resident #13 stated she got in "trouble" by the Acting Administrator three weeks ago for putting a list of her missing clothing on the back of her wheelchair. Resident #13 stated the Acting Administrator got upset with her because her list caused other residents to want to post lists of their missing clothing. 1. She further stated she has been asked prior to this day to leave the facility. The first time Resident #13 was asked to leave, the Owner told her he could not trust her and he wanted her to leave after she spoke with a State Surveyor visiting the facility. Resident #13 stated she stayed in her room for three days after that incident to keep out of trouble. 2. Resident #13 stated in early October she was told the facility could not meet her needs. Her family member requested the Facility Social Worker) SW write a letter explaining the reason for discharge and they would "run it pass" the family attorney. Resident #13 further stated she did not receive a letter and the facility Owner informed her she could remain at the facility. 3. The second time Resident #13 was asked to leave; she got in "trouble" for being across the street talking to a terminated employee. The Owner yelled her name several times in front of other people and told her to get back into the building. He told her it was a facility rule that she could not talk to terminated employees and she would need to find somewhere else to live because she was "not playing on his team." Resident #13 said she was afraid they would make her leave the facility for talking to a Surveyor today. Observation/Interview on 11/11/10 at approximately 7:30 AM Resident #13 observed crying at breakfast. Resident #13 stated after speaking to Surveyor, the Acting DON, Social Worker, and Facility Coordinator met with her and told her she had to move from the Facility. She requested Surveyor contact her later. In an interview on 11/11/10 at 8:54 AM the Social Worker (SW) stated she and two other staff members met with Resident #13 and informed her she was unhappy at the facility and the facility could no longer meet her needs. SW stated Resident #13 was requesting changes the facility could not make such as regular eggs instead of powdered eggs, and requesting her blood sugar be checked "numerous" times a day despite the doctor's order for four times a day. A 30 day letter had been drawn up to present to Resident #13 at the time of the meeting but was not presented. The SW stated Resident #13 decided to leave the facility immediately. The SW further stated that no other resident has been discharged for these reasons and the decision to discharge Resident #13 was made by the facility Owner, Acting Administrator, and Facility Coordinator. She did not know if an appeal process was available to Resident #13. In an interview on 11/11/10 at 9:24 AM Resident #13 stated the Social Worker, Acting DON, and Facility Coordinator confronted her and told her the Facility could not meet her needs. She further stated the facility could not or would not explain which needs they were not able to meet. Resident #13 stated the Acting DON told her " she is not happy here " . Resident #13 indicated this continued harassment and pressure over the last seven weeks being told to leave the facility, has been upsetting and difficult; so she decided to leave voluntarily. Resident #13 said she has been crying a lot because she planned to "live out" the rest of her life at the facility with her father who is also a resident of the facility. She expressed concern the facility Owner would retaliate by not allowing her to visit her father since he does not allow terminated residents or employees on the premises. Resident #13 further stated she requested the facility Owner provide her with written permission to visit her father but had not received a letter. Resident #13 stated she is still angry about the facility Owner yelling at her. Resident #13 stated " she was married to an abusive man for [AGE] years and she can still hear the Owner's tone of voice and see him shaking his fist like she was a child or a dog " . She stated it was humiliating. Resident #13 cried throughout the interview and expressed concern for her father's wellbeing. In an interview on 11/11/10 at 3:05 PM Resident #13 was crying and stated she did not feel good about leaving her father at the facility. Resident #13 stated she isolates herself in her room to avoid confrontations and continues to have nightmares of the Owner screaming at her. This she stated causes her blood pressure and sugar to go up. In an interview on 11/11/10 at 4:25 PM the Acting DON stated Resident #13 " teared up during the meeting; and said she would be out by the weekend " . "We were hoping she would make a choice to leave and she did. We did not want to make the choice for her; we just went in to tell her she was not happy here." The Acting DON stated "I did not say she would not have been asked to leave by the end of the meeting" but she volunteered to leave. In an interview on 11/11/10 at 5:00 PM Resident #13's Family Member (FM) stated Resident #13 called on 11/10/10 crying and said the facility told her she was not happy here and had to leave. The FM expressed concern she cannot care for Resident #13 alone because she required medication and insulin checks. The FM stated she does not feel capable of monitoring Resident #13's medical care. She stated Resident #13 loves it at the facility and the residents love her. Review of Nurse Notes dated 11/04/10 at 8:00 a.m. documented Resident #13 interviewed about current medication. Knows the name, frequency and purpose of her medications. "Does state that she does occasionally forget to take medications, sleeps through medications and meals. Especially in a non-structured environment. Also states she sleeps so hard that when she wakes up she is unable to remember whether she has taken medication or not ....Also says vision is failing and worse then it has been." Review of Social Service progress note dated 11/10/10 documented " Social Worker, Acting DON and Facility Coordinator met with Resident #13 and informed her the facility was not able to meet her medical/general needs " . "Res. began to tear up and said I'll be out by tomorrow ". B. ) In an interview on 11/11/10 at 1:50 PM the facility Owner acknowledged talking to Resident #13 "After she came in (the facility), I asked her if it was necessary to talk to someone who had been fired." He denied any confrontation. Resident #13 provided an email dated 11/01/10 she sent to a family member documenting the incident occurring on 10/29/10 involving the facility Owner. The email documented the facility Owner screamed at Resident #13 " to get into the building " . "This was humiliating, degrading and abusive ". Resident #13 further stated in the email she contacted the Ombudsman's office to complain. In an interview on 11/24/10 at 9:15 AM the Ombudsman reported numerous contacts with Resident #13 including one where she stated the facility Owner yelled at her. She also, expressed concern for her father who is a resident at the facility. He encouraged her to file a complaint with DADs. The Ombudsman stated this is not the first complaint he received related to the Owner ' s aggressive behavior. Another resident complained the Owner was confrontational and yelled at a facility administrator that came to the Facility to assess a resident for transfer. In an interview on 11/24/10 at 11:11AM the Other Administrator acknowledged a confrontation with the facility Owner when he came to the facility to assess adapative equipment of an individual requesting to transfer. He stated " The facility Owner jumped out of his truck and told me I was not welcome there. " He was " angry, abrasive and very confrontational. " He then chastised the resident by saying " You do this after all I have done for you. " The resident discharged from on the facility that day. In an interview on 12/02/10 at 2:31 PM a former employee confirmed witnessing the facility Owner yelling at Resident #13 on 10/29/10 in front of the facility and stated any employee or resident terminated from the facility is not allowed on the premises. Former employee was told by a police officer she would be arrested if she returned to the premises to see her grandmother who is a resident of the facility. In an interview on 11/11/10 at 5:00 PM Resident #13's Family Member (FM) stated she was present when the facility Owner burst out the door screaming "(Resident #13) get over here right now, you are not allowed to speak to terminated employees" . Resident #13 went to her room and the owner later came to her and " repeated that she was not allowed to talk to terminated employees " . FM stated Resident #13 then "cried a lot" after the owner confounded her again C.) During an interview on 11/10/10 at 10:50 AM Resident #13 stated the Owner told her he could not trust her and he wanted her to leave after she spoke with a State Surveyor. She stated she stayed in her room for three days after that incident. Resident #13 stated in early October her family member requested the Facility SW write a letter explaining the reason for discharge and they would "run it pass" the family attorney. Resident #13 further stated she did not receive a letter and the facility Owner informed her she could remain at the facility. Review of Letter dated 10/07/10 documented Owner asked Resident #13 to attend a meeting with him and the Facility Coordinator. The Owner "kindly and respectfully asked (Resident #13) to make other living arrangements for her and her father since she was not happy with the current conditions." Review of Nurse Notes dated 10/08/10 at 1:30 PM revealed " physician's office called and was notified that Resident #13 had not been out of her room since yesterday afternoon after being informed her and her father would have to find another place to live." Review of Social Service Notes dated 10/12/10 documented "Res reports she was asked to Leave the facility and is confused as to whether or not she will continue to live here. Res says she was able to speak with the Owner, last night and she was told last night she would Be able to stay ...Resident requested to be alone in her room to think about the situation." On 11/11/10 at 3:52 PM the IJ was announced to the Owner of the facility who state, " We have been dealing with this for six months ...What happens to her, we still don't want her here?" In an interview on 11/16/10 at 7:15 PM Resident # 17 stated she went to the office the other day and the Owner ask her how it was going and she told him everyone is upset as they are only to have meat with breakfast two days a week now. She reported the Owner told her " that's what the state says and if you don't like it you can gp somewhere else". Resident #17 stated this was "offensive" for him to talk to me this way. She further said it was upsetting what happen to Resident # 13 and how the facility treated her. She stated "it is our fault as Resident #13 was our president and we would tell her our concern...then she got in trouble for them". The Plan of Removal as submitted by the facility was as follows: 1) Shift by shift in-service training with all staff, all disciplines regarding prevention of Abuse specifically regarding psychological harm and also focusing on "good" customer service approaches to handle concerns (complaints) voiced by residents. These in-services will be documented for content and attendance and will continue for next three full days to insure maximum number of staff is exposed to the in-service. a. At this training, Abuse Prohibition policies will be reviewed. b. Focus on techniques for staff response to concerns/complaints voiced by residents or others in facility. c. Review grievance/concern process. d. Remind that ALL verbal concerns/complaints be documented on the Grievance/Concern Intake form and follow-up documented and conveyed to the resident/family member/staff involved. e. Review Resident Rights regarding Transfers and Discharges, who can make that decision, and content of such notices, including right to appeal and advocacy opportunities. f. Strategies for dealing with burn-out and "difficult" situations. g. This material will be incorporated into all "new hire" orientation packets and all "new hires" will be required to complete this training prior to first shift in facility. h. Facility will utilize Consultant, in a consultant role to train Facility Coordinator, in a train-the-trainer mode to teach this material to all new hires. Updates will be on-going as identified by the facility and the QAA process. 2) General in-service training with all staff on next payroll date, 11/12/2010, 2:00 PM with emphasis on approaches to deal with concerns voiced by resident as noted above. a. Review of staff responsibilities and review of "eviction" process and who can initiate and what valid reasons exist. b. Review of facility policy regarding "evictions." c. Review of who gets to decide if we can "meet the resident's needs" i. Resident/family input ii. Clearly documented medical issues requiring transfer iii. Assessment of needs and ability to provide for these needs 3) Special called Resident Council meeting on Friday, November 12, 2010 at 10:30 AM to discuss grievance/concern process and to (re)assure residents that staff are here to serve them and to assist in making Facility as pleasant a place to live as possible. Staff will encourage residents to voice any anxieties or concerns so that staff may provide interventions as appropriate, including professional services as indicated. 4) Letter to all families outlining Facility Policy for Raising and Addressing Concerns with copy included in letter. a. Include a letter invitation to next Family Council meeting where this topic will be included on the agenda. b. This letter will be mailed on Friday, November 12, 2010, to the persons identified as either Responsible party or first next of kin in the clinical record of all current residents. An invitation will also be mailed to the local ombudsman and the medical director at this time. c. Next Family Council meeting will be scheduled for Monday, December 5, 2010 at 7:00 PM. The meeting will be held in the facility dining room. d. Invite families to ask questions and voice concerns in the letter. e. Contract professional for psychological intervention. Contractor with an Advanced Nurse Practitioner in Psychiatry. f. Contracted services are provided weekly and may include group services if such need is identified. g. Contract with Contractor (or other similar professional) to provide concerns in a professional and appropriate manner to prevent concerns in a professional, appropriate manner to prevent psychological harm. This training to be provided as soon as can be arranged and no later than 13 days from this date, or no later than November 24, 2010. h. Advise of availability of Ombudsman and provide contact numbers in letter. 5) Regarding discharges of residents to another facility, Oaks will provide: a. All information necessary to receiving facility to ensure continuity of care will be provided by Facility upon request. b. Facility Social Worker will place follow-up call to Social Worker at receiving facility to establish professional relationship and facilitate transfer of any information requested. c. HIPAA and other protections will be observed for the protection of Resident #13, as well as for all residents of the Facility. 6) Facility will forward attached letter to Resident #13, including information on providing records to facilitate continuity of care. 7) The QAA committee will review this process and ensure that all components are being followed to ensure no resident receives any psychological harm. a. The Administrator will bring Concern/Grievance book to each QAA committee meeting and will review concerns and responses. b. The QAA committee will recommend Action Plans be developed where ongoing or targeted issues need to be addressed. The Action Plans will include specific target dates for completion with individual accountability identified. c. The QAA committee will ensure the involvement and advice of the Medical Director on review of Concerns/Grievances. d. The QAA committee will meet quarterly with the date and time published at least two weeks in advance and specific invitations delivered by mail or fax to QAA committee members, as identified in the QAA policy. e. The next QAA meeting will be scheduled for Wednesday, December 1, 2010 at 1:00 PM to establish a new quarterly pattern and for the purpose of including the newly hired Administrator. While the IJ was removed on 11/11/10 at 10:20 PM after the plan of removal was accepted, the facility remained out of compliance at a level of potential for more than minimum harm at a pattern because all staff had not been trained on abuse and neglect policy and procedures. Seventy-eight residents could be affected by the deficient practices.

Based on observation, interview and record review the facility failed to supervise and monitor one (1) of 6 residents reviewed for accidents who was located outside in the facility courtyard, unresponsive in his wheelchair two hours after after residents sitting at the same dining table asked staff where he was because he had not come to the dining room to eat lunch. (Resident #10) . This resulted in an Immediate Jeopardy (IJ). While the IJ was removed on 9/9/10, the facility remained out of compliance at the level of actual harm/isolated that is not an IJ because the facility administrative staff had not had time to ensure development and implementation of interventions for the adequate supervision of residents to prevent recurrence of similar incidents or conduct all in-services outlined in their plan of removal. This deficient practice resulted in Resident #10 suffering heat stroke after sitting outside in the courtyard in 97 degrees Fahrenheit (F.) heat, with a heat index of 103 degrees F. Resident #10 required hospitalization , medical treatment and resuscitation with intravenous (IV) fluids. The findings include: Review of Resident #10's clinical record reflected an admission date of [DATE] and the following Diagnosis: [REDACTED]. Review of the facility investigation report for Resident #10, dated 8/14/10, reflected Resident #10 was found at 1:30 PM on 8/14/10, unconscious, on the patio courtyard outside of the dining room. The report further reflected Resident #10 had not been seen since approximately 11:00 AM and it was not known how long he had been outside. Further review of the investigation report reflected at 1:30 PM on 8/14/10 the facility's volunteer gardener entered the facility and alerted the staff that Resident #10 was in distress in the courtyard outside of the dining room. Review of the hospital clinical record for Resident #10, dated 8/14/10, reflected the following in the hospital admission history and physical: On arrival to the emergency department Resident #10's was unresponsive and had an ear temperature was 106.3 Fahrenheit (F). Resident was dehydrated and had altered mental status secondary to hyperthermia. Resident #10 was resuscitated with infusions of two Intravenous fluid (IV)sites and ice packs to the groin and axilla. Laboratory results exhibited dehydration so Resident #10 was admitted to the medical floor for further fluid resuscitation and observation. Review of the National Weather Channel data reflected the temperature for Burnet, Texas on 8/14/10 at 1:00 PM was 97 degrees F with a heat index of 103 degrees F. Review of Resident #10's hospital discharge summary reflected he regained consciousness after the fluid resuscitation and was transferred back to the facility at 12:00 PM on 8/15/10. Observation on 8/23/10 at 10:15 AM revealed Resident #10 wheeling himself in his wheelchair down the hall toward the dining room. In an interview on 8/23/10 at 10:20 AM Resident #10 stated he likes to go outside and is usually taken out to the porch by staff members because he cannot open the door and roll his wheelchair by himself. In an interview on 8/23/10 at 11:00 AM the facility's Interim Director of Nurses (DON) stated there were no interventions in place for missing residents. She further stated the investigation report completed on 8/15/10 reflected that one would be developed. She further stated to her knowledge no in-services were done for the staff after the incident on 08/14/10 with Resident #10. The DON stated she was not aware that the former Administrator had included in the investigation report dated 8/15/10 that a door alarm would be installed on the dining room door leading to the courtyard. Observation on 8/23/10 at 11:30 AM of the door in the dining room which leads to an outside courtyard revealed a non-functioning door bell, which had a push button on the outside; however no alarm had been installed. Further observation revealed all of the blinds on the windows and doors were closed and the courtyard was not visible from the dining room. Upon request by the investigator, the blinds were opened and revealed that the courtyard was not visible from anywhere in the dining room except standing next to the windows. Observation of the courtyard from the windows revealed many areas of the courtyard were not visible due to plants, trees and the layout of the courtyard, therefore if someone went out into the courtyard they would not be visible at all times once they were away from the door. Observation further reflected residents in wheelchairs would not be visible due to the height of the wall in the dining room. Observation of the courtyard on 8/23/10 at 11:40 AM revealed an 'L' shaped courtyard with planting beds with trees and plants, winding sidewalks throughout the courtyard and an arbor leading out a gate to an area behind the facility. In an interview on 8/23/10 at 11:40 AM the Assistant Director of Nurses (ADON) stated the gate leading behind the courtyard was not locked, and demonstrated that the gate could be opened with ease. In an interview at 10:00 AM on 8/24/10 the Assistant Director of Nurses (ADON) stated she thought there was supposed to be an alarm or bell installed on the door. Observation by the ADON confirmed there was no alarm and the door bell was not functional. The ADON further stated the window blinds in the dining room are closed most of the time because of the heat. In an interview 12:30 PM on 8/24/10 the Maintenance Supervisor (MS) stated he had installed a door bell, however it was not currently working and he would go buy what he needed and fix the alarm. In an interview on 8/24/10 at 3:25 PM the ADON stated Resident #10 eats lunch everyday in the dining room at the same table however, he did not come to the dining room to eat lunch on 8/14/10. In an interview on 8/24/10 at 3:35 PM CNA F stated Resident #10 did not come to the dining room on 8/14/10 for lunch. She further stated she was asked by the other residents that usually eat with him but she did not look for him because she thought he would come later. CNA F stated if residents do not come to the dining room the staff does not look for them. In an confidential interview on 8/24/10 at 3:40 PM two alert and oriented residents stated they asked an aide if Resident #10 was eating lunch in his room on 8/14/10 but the staff stated she did not know and that he would probably be along later. The two residents further stated Resident #10 did not come to lunch that day and then he was found outside. Observation on 8/25/10 at 10:00 AM revealed a door bell which could be activated from the outside. However it would only ring one time when the door was opened. The nurse surveyor activated the door bell at 10:05 AM and waited for someone to respond. At 10:10 AM a staff member who was attending a meeting in a conference room off of the dining room responded however when asked, the staff at the nurse's station stated they did not hear the door bell. In an interview on 8/25/10 at 10:30 AM the new Director of Nurses (DON) stated she did not think that the door bell was adequate to alert the staff that someone had gone out of the door and that until an alarm could be installed the staff would immediately begin monitoring of the door and the outside courtyard every 20 minutes from 6:00 AM until 10:00 PM. After administrative and enforcement review of the evidence obtained by the investigator from 08/23/10 through 08/25/10 it was determined that additional information was needed. The investigation was reopened on 9/9/10. In an interview on 9/9/10 at 5:10 PM the Interim DON and the ADON stated there was no additional documentation of the door and courtyard monitoring. The DON confirmed that monitoring of the door should have been conducted every 20 minutes between 6:00 AM and 10:00 PM from 8/25/10 thru 8/30/10. Review of the door monitoring documentation dated 8/25/10 thru 8/29/10 reflected the following: 8/25/10-No documentation of door or courtyard monitoring 8/26/10-No monitoring from 6:00 AM thru 10:20 AM, no monitoring from 8:00 PM thru 9:20 PM 8/27/10-No monitoring at 1:00 PM, 1:40 PM, 2:20 PM, from 3:00 PM until 3:40 PM, and none from 6:20 PM thru 10:00 PM 8/28/10-No monitoring from 6:00 PM thru 10:00 PM 8/29/10-No monitoring from 5:00 PM thru 10:00 PM 8/30/10-No monitoring of door or courtyard monitoring In an interview on 9/9/10 at 6:05 PM the Maintenance Director stated a door alarm was installed on the door leading to the courtyard on 8/30/10. He further stated the door alarm is loud and must be deactivated with a key which is on the nurse key ring. On 9/9/10 at 6:20 PM the Interim DON and ADON were informed that an Immediate Jeopardy existed. On 9/9/10 at 8:10 PM the Interim DON and ADON provided the investigator with a written Plan of Removal of the immediacy, which documented the following. ' The following has been done to remove the immediate jeopardy related to the incident, which occurred on 8/14/10. However, there was failure to put in place a policy and procedure to prevent this happening again. The IJ continued to exist from 8/14/10 - 8/30/10 when the proper door alarm was installed. 1. Staff were in-serviced on leaving residents outside unattended on 8/15/10. They were, also, in-serviced on checking on residents every 2 hours and locating any resident missing at mealtime on 8/15/10. 2. Signs were placed on the patio door warning of exit only and that residents were not to be left unattended. This occurred on 8/23/10. 3. Policy and procedure on elopement and missing residents developed, implemented on 8/25/10 and in-serviced on 8/25/10. 4. Monitoring of patio/garden area in-serviced on 8/25/10. 5. Proper keyed, audible door alarm installed on 8/30/10. The above actions did not fully address the supervision needed to ensure the resident's safety; therefore, the following will now be implemented: 1. Further in-servicing of staff to ensure a higher level of supervision of residents will begin 9/9/10. To include, but not limited to, checking residents a minimum of every 2 hours, missing med times and reporting residents missing at meals. ' Based on observations and interviews on 9/9/10 between 8:10 PM and 10:40 PM of staff being in-serviced on the missing resident policy and procedure, resident supervision, the abuse/neglect policy and procedure, the functioning door alarm and interviews with staff regarding their understanding of the missing resident policy: The investigator informed the Interim DON and ADON on 9/9/10 at 10:40 PM, the immediacy no longer existed. However, the deficient practice remained at the level of the potential for more that minimal harm/isolated that is not Immediate Jeopardy (IJ), because the facility had not had time to in-service 100% of their staff on the interventions for missing residents and resident supervision, implementing a higher level of resident supervision and documenting every 2 hours resident checks and in-service 100% of their staff regarding the new door alarm policy and procedure. The facility's ADON provided the number (32) of residents who are mobile.