Every finding on record at Avir at Heritage Oaks

Based on observation, interviews and record review, the facility failed to notify the residents physician regarding a change in the resident's condition, for 1 of 10 residents (Resident #1) reviewed for changes in condition. LVN A failed to notify the physician when Resident #1 complained of abdominal pain, and penile pain on 7/31/2026 at approximately 8:00 PM and bleeding from the penis after attempting to re-insert a Foley catheter on 8/1/2026 at approximately 3:30 AM. LVN A did not notify the physician of Resident #1's changes until 6:19 AM on 8/1/2026. An Immediate Jeopardy (IJ) was identified on 08/07/2026 at 4:38 PM. The IJ template was provided to the facility on [DATE] at 4:46 PM. While the IJ was removed on 8/08/2026 at 4:07 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. This failure could place residents at risk of not having the physician notified of changes resulting in a delay in decision making and medical treatment and worsening of health conditions.Findings Included:Record review of Resident #1's Face Sheet, dated 08/06/2026, revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included: obstructive and reflux uropathy (a blockage that stops urine from flowing normally through the body), Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms (a non-cancerous growth of the prostate gland that presses on the urethra-the tube that connects the bladder to the outside of the body), and chronic kidney disease-stage 3 (moderate kidney damage). Record review of Resident #1's Quarterly MDS assessment, dated 5/23/2026, Section C - Cognitive patterns revealed a BIMS score of 09, which indicated Resident #1 had moderate cognitive impairment. Review of Section H - Bowel and Bladder - revealed Resident #1 had an indwelling catheter (a soft tube placed inside the body to drain urine from the bladder). Record review of Resident #1's Comprehensive Care Plan revealed: I [Resident #1] have DX of obstructive and reflux uropathy, resulting in impaired urinary flow and retrograde urine reflux [reverse direction of normal urine flow], placing the resident at risk for urinary tract infection (UTI), renal impairment [reduced kidney function], urinary retention [inability to fully empty the bladder], hydronephrosis [the swelling of one or both kidneys because urine cannot drain properly and backs up into the organ], pain, and altered elimination [disturbance in the body's ability to expel waste products]. Date Initiated: 03/14/2026. Further review of Interventions/Tasks revealed: Monitor for flank [side of the body between the rib cage and hip bone], abdominal, or suprapubic [above the pubic bone] discomfort. Date Initiated: 03/14/2026. Report signs/symptoms of UTI (.pain, .blood in urine). Date Initiated: 03/14/2026. Further review revealed: Focus: The resident [#1] has 16Fr [denotes size of catheter tube] Indwelling Catheter for Neurogenic bladder [lack of bladder control caused by nerve damage]. Date Initiated: 05/04/2026. Interventions/Tasks: .Monitor/record/report to MD for s/sx UTI: pain.blood tinged [small amount of blood] urine.increased pulse, increased temp [body temperature] .Date Initiated: 05/04/2026. Record review of Resident #1's current Physician's Orders, dated 08/06/2026 revealed: Change 16F [denotes catheter tubing size] 10cc bulb [denotes volume capacity of balloon used to hold the catheter in the bladder] q month on [sic] and PRN with an order date of 02/10/2026. Further review revealed: Monitor urinary output every shift for urinary retention with a start date of 02/11/2026. Record review of Resident #1's MAR, dated 7/1/2026 - 7/31/2026 revealed: Resident #1's catheter was changed on 07/19/2026, according to the order to change the resident's catheter monthly. Further review revealed: Monitor urinary output every shift for urinary retention and was initialed by a licensed nurse each shift. Record review of Resident #1's vital signs did not reveal any documented blood pressure, temperature, respirations, oxygen saturation (measurement of the ability of the blood to carry oxygen), or heart rate for 7/31/2026 to 8/1/2026. Record review of Resident #1's progress note created 8/1/2026 at 7:39AM by LVN A revealed: 21:41 [9:41 PM] Resident [#1] stated that foley catheter [tube inserted through the urethra into the bladder to drain urine into a collection bag] was causing him pain. Attempted to flush without success. Pulled out foley and attempted to change it and resident [#1] refused to have it put back in. Attempted a second time and resident [#1] did not want it back in. 03:30 [3:30 AM] Resident [#1] stated he was ready to have foley back in. Attempted catheter placement and got small return of clear urine. Resident [#1] stated it was too painful and wanted it taken out. While pulling out foley, a small amount of blood was noted. While foley was out resident [#1] had 3 brief changes prior to foley replacement. 04:30 [4:30 AM] Was informed that resident was having blood clots. When assessing resident, minimal was [sic] blood was noted at that time. Attempted to contact [Name] NP. Was awaiting call back. 06:15 [6:15 AM] CNA [B] reported to this nurse that resident had a lot of bleeding. 06:19 [6:19 AM] Spoke with NP. Received orders to send [Resident #1] to ER. Attempted to call [transportation] and [transportation] Ambulance. They stated it would be 3-4 hrs before they could get to the facility. 06:41 [6:41 AM] 911 called. 06:51 [6:51 AM] EMS arrived. Resident [#1] was transported to [Name] ER Record review of hospital records for Resident #1 revealed: [Resident #1] transported to nearby hospital [Name] ER ReportsVital signs upon ER admission: 7:30AMTemperature - 101.7 (Fever)Heart Rate - 118 (high heart rate)Blood Pressure: 69/59 (low Blood pressure)Respiration rate: 18 breaths/minReview of Systems:Tenderness of penis with discharge of blood clots present. Generalized abd [abdominal] tenderness. UTI associated with indwelling catheter, severe sepsis [a life-threatening medical emergency that happens when the body has an extreme, harmful reaction to an infection] with septic shock [a life-threatening medical emergency where an infection causes a severe drop in blood pressure and organ failure], urosepsis [a life-threatening medical emergency that happens when a urinary tract infection (UTI) spreads into the kidneys and then into the blood].Assessment and Plan from ER:Abdominal: General: Abdomen is flat. Palpations [physical exam done with hands]: Abdomen is soft. Tenderness: There is generalized abdominal tenderness. There is no guarding [protective reflex] or rebound [sharp pain when pressure is released from the abdomen]. Genitourinary [relating to the genital and urinary organs]: Penis: Tenderness and discharge (blood/clots) present.Resident was admitted to MICU [Medical Intensive Care Unit] for urosepsis, hypotension [low blood pressure] and acute [sudden] kidney failure precipitated [caused] by infection. During an observation and interview on 08/07/2026 at 10:42 AM, Resident #1 remained hospitalized and was observed resting in bed in his hospital room. The resident stated he had been hospitalized for a good while and thought he would be discharged in the next day or two. Resident #1 stated he recalled the last evening he was at the nursing facility and stated, I got my catheter put in months ago and it's been okay. I told them [CNA B and LVN A] that evening, sometime after dinner, that it started hurting. I may have taken some Tylenol, but I don't really remember. She [LVN A] came and took my catheter out and I asked her to leave it out because it was hurting me. I don't remember what time, but it was late and I asked to have the catheter put back in because I was pissing on myself. She [LVN A] put it back in but it was hurting worse than before, so I told her to take it back out and that's when the bleeding started. I remember that it [bleeding] got worse and the diaper was pretty full of blood. I was hurting more but I probably didn't ask for more pain medication. I did ask a time or two if they would call my doctor or call the hospital or something - but I didn't push it - because I'm not a bitcher. But I did push later when I was really hurting more. The bleeding was pretty bad - it kept getting worse and it filled three or four diapers. I think they said they called the doctor, but they didn't get a response. I don't remember how long it was, but it seems like forever when you're hurting. The ambulance did come later, or maybe the next morning and took me to the ER. Resident #1 stated he had antibiotics in the vein while he was in the hospital and the doctor told him he had a bad infection. During a telephone interview on 08/07/2026 at 1:43 PM, the NP stated she was familiar with Resident #1and recalled receiving a text message and a phone call regarding the resident having some issues with his Foley catheter. The NP stated, I was not the provider on call that night. I'm not sure why I received the text message in the middle of the night or the phone call, but I was already on the phone with the nurse, so I told her to send the resident out to the ER. She [LVN A] should have called sooner. I can understand on the weekend, but she should have called earlier by 8 or 9 PM to at least update and to notify that she didn't put the Foley back in and notify of changes and pain. I would have expected an SBAR [Assessment tool that identifies Situation, Background, Assessment, and Recommendation] - she didn't write anything down, any vitals, that's sketchy, and I don't know if she went through the call center [call service to notify the on-call provider of a message] or not? She needs to be retrained or let go but I am not sure what the facility policy is. I expect to be notified of any abdominal pain or bleeding after a Foley insertion attempt, especially if they have a history of uropathy [any abnormality affecting the urinary tract] or BPH because it can cause obstruction [block] and urosepsis. The NP stated the failure to notify of changes for Resident #1 put him at risk for sepsis, a ruptured bladder [a serious medical emergency where the wall of the bladder tears causing urine to leak into the belly or pelvis], acute kidney injury or death. During an interview on 08/07/2026 at 6:21 PM, LVN A stated she was the night charge nurse on 07/31/2026 on [Name] Hall and took care of Resident #1. LVN A stated, I went to his [Resident #1] room in the early evening to put his ordered medicated cream on his neck and he told me his catheter was hurting and pointed to his lower abdomen and bladder area. I pushed on his abdomen but didn't feel any distention [swelling]. I took his vital signs, but I forgot to write them down. I remember he didn't really have any fever - it was around 97 [degrees] or so I think. Around 8:30-9 [PM] he [Resident #1] was complaining of penile pain and I saw some sediment [solid matter that settles in the bottom of a liquid] in the catheter tubing so I got supplies and tried to flush the catheter, but it wouldn't flush at all so I decided to change it out. The supply room was locked so I texted the ADON at 8:48 PM but did not hear back from her so I texted the DON at 8:59 PM to let her know I needed catheter supplies for [Resident #1]. CNA C told LVN B what was going on and LVN B brought me the supplies I needed so I texted the DON back at 9:32 PM to let her know I had the supplies for the catheter change. I went back to the resident's [#1] room and removed the catheter. Quite a bit of urine came out when I took it out and the resident said it felt better out and refused to have it replaced at that time and I left it out. He [Resident #1] had three wet brief changes after that. Around 3:30 [AM] the resident [#1] requested his catheter to be replaced. I inserted a new catheter tube easily without any resistance on insertion. When I went to inflate the balloon he [Resident #1] immediately started complaining of pain again and told me he wanted it taken out. When I removed the catheter there was some bright red bleeding - probably about the size of a half-dollar - on the brief. CNA C changed him [Resident #1] a couple of times after that and reported that there was blood in his brief. I checked the brief when CNA C changed the resident [#1] and noted some blood, but it was not a lot. From around 3:30 [AM] on, the resident's [#1] pain was increasing and I did have some concern about retention [inability to empty the bladder] which is why I was monitoring for wet briefs. A little later in the shift there was a lot of blood in the brief and on the sheets and the resident [#1] was complaining of pain again. I texted [Name] NP at 4:35 [AM] to let her know what had gone on during the shift but I did not get a response. At 6:09 [AM] I got a text message from the DON wanting to know what was going on with [Resident #1]. Apparently, CNA C or LVN B called her instead of bringing their concerns to me. At 6:19 [AM] I called [Name] NP and she stated she was not on call but from the text message and since she was already on the phone with me, she said to send the resident [#1] to the hospital. I called [Name] ambulance, but they said it would take 3-4 hours to get there so I called 911 and the resident [#1] was transported to [Name] ER at 6:51 [AM]. When EMS got there, [Resident #1] was doubled over in pain. LVN A stated she would not have done anything different except try to call [Answering Service] when the text message to the NP was not answered. During an interview on 08/07/2026 at 7:32 PM, LVN B stated she was working as the night charge nurse on 07/31/2026 on [Name] Hall. She stated she was familiar with Resident #1 and had worked on the hall he resided on before but was assigned to a different hall that night. LVN B stated, Around 7:30-8 [PM] CNA C walked over to my station and told me [Resident #1] was in pain and she could not locate LVN A. I walked over to that station, but I did not see [LVN A] and one of my residents needed something so I went back to my station. A little while later, CNA C came back and stated LVN A had removed the resident's [#1] catheter but did not replace it because she was waiting for nursing administration to unlock the supply closet. I found the supplies for the catheter insertion on my side and walked them over to LVN A. Around 4 [AM] or so, CNA C came back to my side and asked me to come and check on [Resident #1] because he was in bad pain. When I saw him, he appeared to be in pain, gripping the bed and there was blood in the brief and on the pad and also some blood clots. I found [LVN A] and told her the resident [#1] was in pain and bleeding from the penis and she [LVN A] told me she had already contacted the NP, so I went back to my station to check on my own residents. I gave report at 6 [AM] and went home. When I came back that evening, I found out [Resident #1] was sent out to the ER. In my opinion, he [Resident #1] should have been sent out sooner - I would not have waited on the provider to call back. During an interview on 08/08/2026 at 3:00 PM, CNA C stated she worked the evening of 07/31/2026 on [Name] Hall with [LVN A] and took care of Resident #1. CNA C stated, Around 7PM [Resident #1] called on the call light and I went to his room, and he was complaining that his catheter was starting to hurt. I reported it to [LVN A] because the resident [#1] was telling me to pull it out. Around 8PM he [Resident #1] called again so I checked with [LVN A] and she said she was waiting on supplies so she could change the catheter out. I went to the other hall and asked [LVN B] if she could get some supplies for [LVN A]. At that time, [LVN A] took the catheter out but did not put one back in. Sometime around 3AM the resident [#1] called and wanted to be changed because his sheets were wet. I changed his sheets and he [Resident #1] said he wanted his catheter back in now and I told [LVN A] who said the resident [#1] did not want it back in but she would check with him again. On the 4AM rounds, I took his [Resident #1] brief off and there was no catheter but there was blood and clots. [Resident #1] said the nurse [LVN A] had put the catheter back in but it was hurting too much - he didn't say if he told her [LVN A] to take it out or not but said he was hurting now. I left the brief in place and told [LVN A] so she could see it and she told me she already knew about the bleeding. I went and asked [LVN B] to check on the resident [#1]. He [Resident #1] told [LVN B] that his pain level was a 10 out of 10 and he wanted to go to the hospital. [LVN B] notified [LVN A] and [LVN A] said she had already contacted the NP. I felt conflicted about going to another nurse about the resident, but I felt better after [LVN B] checked on him. I personally did not see [LVN A] take the resident's [#1] vitals. Around 5AM I checked on the resident [#1] again and there was blood on the sheet, and he was again saying he wanted to go to the hospital and [LVN A] said she was waiting for the doctor to call back. Around 6AM I called the ADON but did not get an answer. I called the DON 2-3 times, and she called me back and I told her what was going on with [Resident #1] and that I was worried about him. I didn't feel like [LVN A] was doing enough for him [Resident #1]. Around 6:30 [AM] my relief was at the facility and helped me get the resident [#1] cleaned up. I was still at the facility when EMS picked him up - it was close to 7 [AM]. During a follow-up interview on 08/08/2026 at 3:44 PM, LVN A stated she had received 1:1 education the previous evening from the ADM and DON. She stated she was in-serviced on notifying the provider when a change occurred with a resident's catheter such as the onset of abdominal pain, penile pain, and bleeding. She stated a change of condition was anything different from the residents' baseline and should be assessed through visualizing the resident, taking vital signs and getting information from the resident, when possible. She stated the facility policy for reporting a change in condition to the provider was to notify the provider immediately of any change. LVN A stated a resident who was complaining of a new onset of pain and new or increased bleeding would constitute a change in condition and should be reported to the provider. LVN A stated, In hindsight, I should have called the provider sooner for [Resident #1]. I'm not sure why I didn't? I thought I had texted her earlier in the shift but I didn't. LVN A stated if a provider does not respond timely to a notification of change, the DON should be notified. LVN A stated if a provider has not responded and the situation is a medical emergency, the resident should be sent to the ER. LVN A stated, I should have contacted [NP] when the blood was first seen. LVN A stated a potential negative outcome for failure to notify the provider of a resident's change in condition was declining health condition and death. During an interview on 08/08/2026 at 4:34 PM, the ADM stated she was not aware of the delay in reporting Resident #1's change in condition between 07/31/2026 and 08/01/2026. She stated the policy for notifying the provider was immediate notification upon determination of a change in condition. The ADM stated the provider and the DON should have been notified immediately by LVN A of the changes that occurred with Resident #1 during the shift on 07/31/2026-08/01/2026. She stated a change of condition was any change from the resident's baseline. She stated nursing staff were expected to have the knowledge through their nurse training to recognize and report a change in condition and, if there was a question, the nurse should contact the DON for guidance. The ADM stated a potential negative outcome for failure to make timely notifications for a change in condition was a resident could continue to decline. During an interview on 08/08/2026 at 4:42 PM, the DON stated she was not aware of Resident #1's change in condition until approximately 6:00 AM on 08/01/2026. She stated she was notified of Resident #1's change in condition via phone call from CNA C. She stated she had not been notified by LVN A of the change in condition for Resident #1. The DON stated the policy for notifying the provider of a change in a resident's condition was to immediately call the provider directly or utilize [Name] answering service to get in touch with a provider. She stated she expected to be notified by staff of any changes in a resident's condition. The DON stated a new onset of pain or bleeding or an increase in pain or bleeding would represent a change in condition and should be reported to the provider. She stated the provider should be notified if a resident with a urinary catheter reports pain or refuses to have the catheter replaced after removal. The DON stated the provider should have been notified at the onset of the change in condition for Resident #1. She stated a nurses' professional education was the basis of knowledge for recognizing a change in condition and her expectation of nursing staff was to recognize and immediately report any changes to the provider, DON and family. The DON stated a potential negative outcome for failure to report a change of condition to the provider was a delay that could result in further decline. Record review of the facility's policy titled, Change in a Resident's Condition or Status, revised April 2025 revealed: Policy Statement Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.)Policy Interpretation and Implementation1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):. d. significant change in the resident's physical/emotional/mental condition;. g. need to transfer the resident to a hospital/treatment center;. i. specific instruction to notify the physician of changes in the resident's condition.2. A significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Record review of the facility's policy titled, Catheter Care, Urinary, revised July 2024 revealed: PurposeThe purpose of this procedure is to prevent catheter-associated urinary tract infections.Complications1. Observe the resident for complications associated with urinary catheters.c. Notify the physician/physician extender, or supervisor in the event of bleeding.d. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area.e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician/physician extender or supervisor immediately.Reporting1. Notify the supervisor if the resident refuses the procedure.2. Report other information in accordance with facility policy and professional standards of practice. This was determined to be an IJ on 08/07/2026 at 4:38 PM. The administrator and DON were notified on 08/07/2026 at 4:46 PM and the IJ Template was provided. The following Plan of Removal was accepted on 8/07/2026 at 6:04PM. Plan of Removal:580: Notify of ChangesIJ Called: 8/7/2026Failure Statement: LVN A failed to notify the physician when Resident #1 complained of abdominal pain, and penile pain on 7/31/2026 at approximately 8:00pm and bleeding from the penis after attempting to re-insert a Foley catheter on 8/1/2026 at approximately 3:30am. LVN A did not notify the physician of Resident #1's change until 6:19AM on 8/1/2026. How corrective action will be accomplished for those residents affected by the violation(s):Action: Resident #1 was sent to the hospital due to a change in condition on 8/1/2026.Person(s) Responsible: Charge NurseDate: 8/1/2026 How the facility will identify other residents with the potential to be affected by the same violation(s):Action: Progress notes reviewed for 72 hours to search for change in condition that went unreported or delayed in reporting to the physician or physician extender.Any changes noted without physician or physician extender notification will be communicated and the facility will follow any new orders.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 8/7/2026 What measures will be put into place or systemic changes made to ensure the violation(s) will not recur:Action: LVN A was educated 1:1 as it relates to the facility's change in condition policy.LVN A will understand when a resident has a change in condition such as complaining of abdominal pain, penile pain and bleeding to report to the on-call physician or physician extender and follow orders. If the physician or physician extender is not responding promptly to make a nursing judgment and send resident to the hospital for further evaluation.Person(s) Responsible: Director of Nursing and/or DesigneeDate: 8/7/2026 Action: Nurses educated on the facility's change in condition policy with emphasis on change in condition such as complaining of abdominal pain, penile pain and bleeding to report to the on call physician or physician extender and follow orders. If the physician or physician extender is not responding promptly to make a nursing judgment and send resident to the hospital for further evaluation.Nurses will be educated prior to working their next shift to include new and temporary nurses.Person(s) Responsible: Director of Nursing and/or DesigneeDate: 8/7/2026 How the facility will monitor its corrective actions to ensure that the violation(s) is being corrected and will not recur:Action: During clinical meetings, daily, the 24 hour report will be reviewed for any changes in condition by clinical leadership. If change in condition is noted clinical leadership will ensure the physician was notified and any orders were followed. If change in condition was noted and documentation does not indicate the physician or physician extender was notified, clinical leadership will notify the physician and reeducate the responsible nurse.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Weekend Nurse Supervisor, or DesigneeDate: 8/7/2026QAPI:Action: The facility notified the Medical Director of the Immediate Jeopardy of 580: Notify of Changes and the facility's plan to remove the immediacy. No additional recommendations.Person(s) Responsible: AdministratorDate: 8/7/2026Action: The administrator will oversee the action items and will ensure they are completed.Person(s) Responsible: AdministratorDate: 8/7/2026 On 08/08/2026 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 08/08/2026 at 11:07 AM, the ADM stated all licensed nursing staff from the previous night shift on 08/07/2026 and all licensed nursing staff who were working today, 08/08/2026, had been in-serviced according to the POR topics prior to working their assigned shift. The ADM stated LVN A received 1:1 education relating to the facility's change in condition policy and notifying the provider at the onset of changes with a resident with a catheter. The ADM provided in-service training sheets signed by staff members for surveyor review. She stated all weekend staff were in-serviced and the weekday staff for the following week would be in-serviced prior to working the next scheduled shift. The ADM stated progress notes were reviewed by the DON and RCN for any change in condition that went unreported or had a delay in reporting with a 72-hour look back and no issues were identified. She stated the Medical Director was notified and a QAPI meeting was held on 08/07/2026 to discuss the facility's plan to remove the immediacy and there were no additional recommendations made. Record review of an attestation statement, dated 08/07/2026 signed by the DON, stated 72 hours of progress notes for each resident were reviewed for changes in conditions that may have been unreported or had a delay in reporting. Record review of an attestation statement, dated 08/07/2026 and signed by the RCN, stated 72 hours of progress notes for each resident were reviewed for changes in conditions that may have been unreported or had a delay in reporting. Record review of an in-service training for clinical staff dated 08/07/2026 revealed, Subject: Immediate Notification of Resident Changes. Summary of the in-service stated all staff were responsible for recognizing and reporting any change in a resident's condition and documenting it. The DON should be notified immediately when a change of condition was observed, and the physician should be notified immediately to ensure proper medical evaluation and intervention. The document was signed by 13 staff members. Record review of 1:1 training for LVN A dated 08/07/2026 revealed, Subject: One on One Education. The in-service documents revealed LVN A was educated over the facility's change in condition policy, indwelling foley catheter policy, and catheter care urinary policy. Summary of the in-service stated pain at the catheter site, resident request to remove a catheter and bleeding after removal of a catheter should be reported to the physician or physician extender. Any change in condition reported to the nurse by a CNA should be reported to the physician or physician extender. If the physician or physician extender was not responding promptly, make a nursing judgment and send the resident to the hospital for further evaluation. The document was signed by LVN A. Record review of ad hoc (as needed) QAPI meeting summary sheet revealed a meeting was held on 08/07/2026 with discussion of the facility's plan of removal. Plan of action included: review of all progress notes for unreported changes in condition, 1:1 education for LVN A relating to the facility's change in condition policy, education of nursing staff relating to the facility's change in condition policy and using nursing judgement to send a resident to the hospital if timely provider response was not obtained. In attendance were: ADM, DON, ADON and Medical Director (via phone). No additional recommendations were made. On 08/08/2026 between 11:31 AM and 3:41 PM interviews were conducted with the following staff members: LVNs A, D, E, H, I, J, K; RNs F, and J. All staff members stated they were in-serviced on 08/07/2026 or 08/08/2026, prior to beginning their shift. All staff members stated they would notify the provider and DON immediately upon any resident change of condition such as pain, bleeding, changes in vital signs, changes in cognition or behavior. All staff stated they would do an assessment of the resident, note any change in condition from baseline, including vital signs and report the findings to the provider for guidance and orders. All staff stated if a resident had a noted change of condition and timely response was not received from the provider, they would use nursing judgment to send the resident to the hospital. On 8/08/2026 at 4:07 PM, the Administrator was notified that the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effective

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 5 of 8 confidential residents (R#1, R#2, R#3, R#4, and R #5) reviewed for meals. Residents #1, #2, #3, #4, and #5 voiced concerned about not having plates, cups, and eating utensils. These failures could result in a decline in residents' consumption of food and cause residents unwanted weight loss. Findings included: Resident #1Observation on 06/18/26 at 1:18 pm, Resident #1 was offered his noon meal in a Styrofoam container. His meal tray included a fork and 1 serving spoon. The eating portion of the spoon measured approximately 2 inches horizontally and 2 3/4 inches vertically. During a confidential interview 06/18/26 at 1:18 pm, Resident #1 said he has complained to the CNAs and the nurses that his food was not served on a plate, and his utensils include a fork, a large spoon, but not a knife. The CNAs and nurses have informed him that his hallway is the last one to receive their meals, and by the time they serve his food, they have run out of food, plates, and silverware. This is why his food is served in a Styrofoam container. Resident #1 said he cannot eat with a serving spoon because it was too big to fit into his mouth. The eating portion of this spoon measure 2 inches by 2 3/4 inches. Resident #1 said most of the mornings he is not offered a cup of coffee, which he said he likes in the morning. He stated when he has asked for a cup of coffee, he was informed there are not enough coffee cups in the facility. Resident #1 said he has the right to have a hot meal on a plate, and a fork, spoon and knife so he can eat his meal. This has been an ongoing issue for the past two months, and I have complained and complained to the CNAs and nurses, but nothing has changed. During a confidential interview on 06/22/26 at 9:15 am, Resident #1 stated he had a fork and spoon but not a knife to cut his sausage patty. Resident #1 became upset and asked unknown nurse or CNA why he did not have his food on a plate, and they told him it was because the facility was short of plates. Resident #2Observation on 06/18/26 at 1:45 pm, Resident #2 was offered her noon meal in a Styrofoam container. The utensils on her meal tray included a fork but not a spoon or knife. During a confidential interview on 06/18/26 at 1:45 pm, Resident #2 said most of the time her meals are served on a Styrofoam container. Resident #2 said she wants a plate, fork, spoon, and knife to use when eating her meal. During a confidential interview on 06/22/26 at 9:28 am Resident #2 said she was provided with a fork and spoon but not a knife, and she would like a knife. Resident #3Observation on 06/18/26 at 1:49 pm, Resident #3 was offered her noon meal in a Styrofoam container. The meal tray included a fork, but not a spoon or knife. During a confidential interview 06/18/26 at 1:49 pm, Resident #3 said her meals are served on a Styrofoam container. Resident #3 said she would like her food on a plate, and offered a spoon, fork, and knife to eat her meal. Resident #4Observation on 06/18/26 at 1:58 pm, Resident #4 was offered her noon meal in a Styrofoam container. Her meal tray included a fork, but not a spoon or knife. During a confidential interview Resident #4 said most of her meals are served in a Styrofoam container. Resident #4 said she would like her food to be served on a plate and to have a spoon, fork and knife to eat her meals. Resident #4 said she does not always receive her cup of coffee, which she said she likes to drink in the morning. She said they informed her there are not enough coffee cups for her to drink coffee. During a confidential interview 06/22/26 at 9:25 am, Resident #4 indicated her breakfast was disappointing again, because she did not have a knife to cut her sausage patty. Her spoon was not a teaspoon or tablespoon; it was a serving spoon. Resident #2 said she was offered a Styrofoam container for her food, but she would rather have a plate, a fork, normal size spoon, and a knife to eat her meal. Resident #5During a confidential interview on 06/22/26 at 3:49 pm, Resident #5 said most of the time he gets Styrofoam plates for lunch and dinner, because they do not have plates. He also gets plasticware or no spoon for his soup. Resident #5 said he wants regular silverware and hot food on a plate when he eats. During an interview on 06/18/26 at 1:35 pm, LVN A indicated the hall, where Residents #1, #2 #3, #4 and #5 reside, has always been the last hall to receive the resident's meal trays. LVN A stated most of the time, these residents receive their food in a Styrofoam container instead of a plate. LVN A said she has complained to the kitchen staff (unable to recall the names) about the Styrofoam containers and why residents are not offered a fork, spoon, and knife at each meal. The kitchen staff informed her they used the Styrofoam containers because they ran out of plates and there are not enough forks, spoons or knives or coffee cups to offer each resident. During an interview on 06/18/26 at 3:17 pm, CNA B indicated she often sees Residents #1, #2, #3, #4, and #5 offered their meals in Styrofoam containers. These residents complain a lot about their meals not served on a plate, and not offered a fork, spoon, knife, and coffee cups as needed. During an interview on 06/18/26 at 3:25 pm, Staff C indicated she must use Styrofoam containers because there are not enough plates to serve residents their meals. Staff C said the kitchen staff are unable to offer each resident a fork, spoon, and knife for each meal, because there are not enough utensils, and that was why some residents were offered a serving spoon. Staff C said she has been asked to provide coffee to residents in the morning. she told them there are not enough coffee cups in the facility to do that. During an interview on 06/18/26 at 4:20 pm, CNA D indicated daily for the past 2 months, 6 to 7 residents are offered their meals in Styrofoam containers because there are not enough plates. Residents #1, #2, #3, #4 and #5, complained that they are not offered a plate for their food, and that they do not receive a fork, spoon, and knife at each meal. CNA D said she asked Staff C, who said they do not have enough plates and silverware to offer each resident. CNA D said the residents have been complaining that they do not receive a cup of coffee, and she asked Staff C who said it's because they do not have enough coffee cups. During an interview on 06/19/26 at 2:13 pm, ST H had witnessed residents served their meals on Styrofoam containers, and serving spoon bigger than a tablespoon. During an interview on 06/19/26 at 2:47 pm, Staff L indicated she assist with passing trays out to the residents and observed residents with forks but no knife to cut their meats, and she saw residents with a serving spoon big enough to feed two mouths. Staff L said she was informed that there was a shortage of plates and silverware. During an interview on 06/19/26 at 3:15 pm, DON indicated she was unaware the facility did not have enough plates for silverware for the residents. During an interview on 06/22/26 at 9:10 am, Staff E indicated the facility does not have enough coffee cups to give to every resident that wants coffee. Today, 06/19/26, Staff E said he took all the coffee cups they had in the facility and divided them into four halls, and he sent 8 cups of coffee per hallway. During an interview on 06/22/26 at 11:09 am, Staff I said his responsibility includes putting the fork and spoon on the residents' meal tray. He stated today he was directed to add a knife to the residents' trays. Staff I stated he placed a serving spoon on a residents' tray because they did not have enough teaspoons and tablespoons. During an interview on 06/22/26 at 11:36 am, Staff J stated the facility was short of plates and that's' why 5 residents always get the Styrofoam containers, and a resident should be offered a fork and spoon, but not a knife because that was what she was told in the past. Staff J stated that some of the residents are given a large spoon because they do not have enough teaspoons or tablespoons. During an interview on 06/22/26 at 12:05 pm, Staff E indicated on 06/22/26 during the morning meal, he was responsible for sending coffee to Halls AA, BB, CC and DD. He could only provide 8 cups per hallway because there were not enough cups. Staff E said there are not enough teaspoons or tablespoons for the residents, and when they run out, he will use a serving spoon. During an interview on 06/22/26 at 2:13 pm, with MD K indicated he was not informed the facility did not have enough utensils for the residents to eat their meal, and that they did not have enough plates to serve residents their meal, instead they were served on Styrofoam containers. Review of the facility's Key Aspects of Customer Service included Prompt Problem Resolution: Addressing any concerns or issues raised by resident or their families in a timely and efficient Manner is crucial. Promptly acknowledging and resolving problems helps build trust and shows that their satisfaction is a top priority.

Based on interviews and record reviews, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 8 confidential residents (R#1, R#4, and R#6) in that: The facility failed to ensure staff were informed there was a working shower in the facility for residents reviewed for showers in 4 of 4 hallways (Halls AA, BB, CC, and DD). This could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings include:During an interview on 06/18/26 at 12:36 pm, R#6 indicated his showers were at night on Tuesdays, Thursdays, and Saturdays. R#6 said his last shower was on Thursday 06/11/26, and on Saturday 06/13/26 he asked for a shower. R #6 stated he was told by unknown staff there was no hot water. He stated on Tuesday 06/15/26, he asked the unknown night nurse and CNA for a shower, because the last shower he took was on Thursday 06/11/26, 4 days ago, and the CNA responded he can take a shower but it would be with cold water, because there was no hot water. R#6 said he has the right to shower, but they do not always do that. Record review of R#6's shower schedule that was undated indicated R#6's shower days were 6 pm to 6 am on Mondays, Wednesdays, and Fridays. Record review of R#6's Shower/Bath sheet dated 06/02/26 through 06/19/26 indicated yes was marked to indicate a shower was completed on 06/02/26. 06/05/26 was recorded as not applicable, and 06/10/26, 06/14/26, and 06/19 were recorded with no to indicate a shower had been completed. During an interview on 06/18/26 at 12:55 pm, R#1 said his shower days are Tuesday, Thursdays, and Saturdays. On Saturday 06/13/25, he was supposed to take a shower; however, he was informed they were working on the plumbing and he could not take a shower and was not offered a shower in another area of the facility. R#1 said he took a shower on 06/11/26 and it was not until Tuesday 06/16/26 that he was able to take his next shower because there was no hot water. R#1 stated I went 4 days without a shower, and I wanted a shower. I never miss my showers, and it bothers me because it causes me to think too much about my shower. Record review of R#1's shower schedule that was undated was received on 06/22/26, and R#1's name was not included on this report. Record review of R#1's Shower/Bath sheet dated 06/01/26 through 06/22/26 indicated no was marked on 06/01/26 to indicate a shower was completed. 06/02/26, 06/03/26, and 06/04/26 were marked with Yes to indicate a shower was completed. 06/05/26 was marked as not applicable. 06/06/26, 06/08/26, 06/09/26, 06/10/26, 06/12/26, 06/13/26, 06/14/26, were marked with yes to indicate a shower had been completed. 06/15/26 was marked with no to indicate a shower was not completed. 06/16/26, 06/17/26, 06/18/26, 06/19/26, 06/21/26, and 06/22/26 were marked with yes to indicate a shower had been completed. During an interview on 06/18/26 at 1:58 pm, R#4 said she showers on Monday, Wednesday and Friday; however, on Friday 06/12/26 she missed her shower, because when she asked unknown CNA for a shower, she replied I will get to you when I can. R#4 said she reported this to unknown nurse, who said I will direct the CNA to give you a shower, but she never got one. R #4 said she had to wait until Monday 06/15/26, 4 days later, for her shower. Record review of R#4's shower schedule that was undated but received on 06/22/26 did not include R#4's name. Record review of R#4's Shower/Bath sheet dated 06/01/26 through 06/22/26 indicated it was marked no 06/01/26, indicating she did not have a shower. On 06/03/26, 06/08/26,06/10/26, 06/12/26, 06/15/26, 06/17/26, 06/19/26, and 06/22/26 were marked yes, to indicate a shower was completed. During an interview on 06/18/26 at 3:38 pm, LVN A indicated from approximately 06/12/26 to 06/15/26 the common showers in Hall AA, Hall BB, and Hall CC, were not working. LVN A said on 06/17/26 she was informed residents could shower in resident room [ROOM NUMBER], because it was an empty room and the shower was working. LVN A indicated R#6, who was paralyzed, liked to shower because he had bowel movements and urinated on himself. LVN A stated R#1 does not refuse showers. During an interview on 06/18/26 at 4:20 pm, CNA D indicated the showers in Hall AA, Hall BB, and Hall CC, were not working. CNA D said on 06/17/26 she was informed the residents could shower in room [ROOM NUMBER]; however, she did not know this before 06/17/26. CNA D said for those wanting a bed bath she would warm up the water in the microwave for approximately 1 minute. During an interview on 06/19/26 at 2:13 pm, LVN N said on Friday 06/12/26, she was informed that residents could shower in room [ROOM NUMBER]; however, prior to 06/12/26, R#6 was offered a bed bath, but he refused because he wanted his shower. R #1 wanted a shower but could have one because we had not been notified residents could use room [ROOM NUMBER]. During an interview on 06/19/26 at 2:47 pm, Staff L said the showers had been an ongoing problem because the water was not getting hot. All the showers were out, and it was not until 06/18/26 that she was notified residents could shower in room [ROOM NUMBER]. During an interview on 06/19/26 at 4:36 pm, DON said at admission residents are informed that they will be offered 3 showers a week and they can choose if they want the shower during the day or night. If a resident, who was alert and interviewable indicates they did not receive a shower, it's because they probably did not get one. During an interview on 06/22/26 at 3:36 pm, MS M indicated since 04/15/26 the shower on Hall AA was out of order; however, approximately 2 weeks ago the shower's water heater was replaced. On 06/09/26 he closed the common showers in Hall BB and Hall CC because Hall BB's temp was too low, and Hall CC was draining to the basement; however, the residents could use room [ROOM NUMBER] for showers.

Based on observation, interview, and record review, the facility failed to provide resident with food and drink that was palatable, attractive and at a safe and appetizing temperature for 5 of 8 confidential residents (Residents #1, #2, #3, #4, and #5) reviewed for food palatability in that: Residents #1, #2, #3, #4, and #5 voiced concerned about cold food and bread that was wet, soggy, and not toasted. This failure could result in a decline in residents' consumption of food, cause residents unwanted weight loss, and/or food borne illness. The findings included: Observation and confidential interview on 06/18/26 at 1:18 pm , Resident #1 was offered his noon meal in a Styrofoam container. This container included a Philly Steak, mashed potatoes, tossed salad and pudding. On the meal tray there was a 4-ounce glass of punch, Dash-salt free packet, one pepper packet, and one sugar packet. Resident #1 said most of the time his meal will not match the Meal Ticket. He said he has complained to the CNAs and the nurses that his meals are cold. Resident #1 said he has been informed that his hallway was the last one to receive their meals, and they must add food that do not match his Meal Ticket, because they run out of food. This is why his food was served in a Styrofoam container causing his food to be cold. Resident #1 said his food was always cold because his food was not on the metal plate that kept the food hot. Resident #1 said most of the mornings he was not offered a cup of coffee, which he said he likes in the morning. Resident #1 said when he asked for a cup of coffee, he was informed there are not enough coffee cups in the facility. Resident #1 said he has the right to be served a hot meal that matches his Meal Ticket and this has been an ongoing issue for the past two months. He said, I have complained and complained to the CNAs and nurses, but nothing has changed. Record review on 06/18/26 at 1:18 pm, Resident #1's Meal Ticket on his meal tray indicated he was on Reduced Concentrate Sweets, regular texture, and thin liquids. This ticket indicated he should have been served, a Philly steak sandwich, potato wedges (substituted with mashed potatoes), tossed salad dressing of choice (not offered), ketchup (not offered), and cheesecake (substituted with pudding). Observation and confidential interview on 06/18/26 at 1:45 pm, Resident #2 was offered her noon meal in a Styrofoam container. This container included a Philly Steak, mashed potatoes, tossed salad and pudding. On the meal tray there was a 4 oz glass of punch, one salt packet, one pepper packet, and one sugar packet. Resident #2 said most of the time her meals are served on a Styrofoam container and these meals are cold. Resident #2 said she wishes her food was hot. Record review on 06/18/26 at 1:45 pm, of Resident #2's Meal Ticket on her meal tray indicated she was on a Regular diet, Regular texture, and thin liquid. This ticket indicated she should have been served, a Philly steak sandwich, potato wedges (substituted with mashed potatoes), tossed salad dressing of choice (not offered), ketchup (not offered), and cheesecake (substituted with pudding). Observation and confidential interview on 06/18/26 at 1:49 pm, Resident #3 was offered her noon meal in a Styrofoam container. This container included a Philly Steak, mashed potatoes, tossed salad and pudding. On the meal tray there was a 4 oz glass of punch, one salt packet, one pepper packet, and one sugar packet. Resident #3 said her meals are always cold and always served in a Styrofoam container. Resident #3 said she would like her food to be hot. Record review on 06/18/26 at 1:49 pm, Resident #3's Meal Ticket on her meal tray indicated she was on Reduced Concentrate Sweets, regular texture, and thin liquids. This ticket indicated she should have been served, a Philly steak sandwich, potato wedges (substituted with mashed potatoes), tossed salad , dressing of choice (not offered), ketchup (not offered), and cheesecake (substituted with pudding). Observation and confidential interview on 06/18/26 at 1:58 pm, Resident #4 was offered her noon meal in a Styrofoam container. This container included a Philly Steak, mashed potatoes, tossed salad and pudding. On the meal tray there was a 4 oz glass of punch, one salt packet, one pepper packet, and one sugar packet. Resident #4 said most of her meals are served in a Styrofoam container, which cause her food to get cold. Resident #4 said she would like her food to be hot. Resident #4 said she does not always receive her cup of coffee, which she said she likes to drink in the morning; however, they inform her there are not enough coffee cups for her to drink coffee. Record review on 06/18/26 at 1:58 pm, Resident #4's Meal Ticket on her meal tray indicated she was on Reduced Concentrate Sweets, regular texture, and regular consistency. This ticket indicated she should have been served a Philly steak sandwich (, potato wedges (substituted with mashed potatoes), tossed salad, dressing of choice (not offered), ketchup (not offered), and cheesecake (substituted with pudding). During a confidential interview on 06/22/26 at 3:49 pm, Resident #5 said most of the time his meals are offered to him in a Styrofoam Container because they do not have any plates, and the foods cold. Resident #5 said he want hot food on a plate when he eats. During an interview on 06/18/26 at 1:35 pm, LVN A indicated the hall that includes Residents #1, #2 #3, #4 and #5, has always been the last hall to receive the resident's meal trays. Most of the time, these residents receive their food in a Styrofoam container and their food was cold. LVN A said she has complained to the kitchen staff (unable to recall the names) about the Styrofoam containers with cold food, and the food not matching the Meal Ticket. These staff informed her they used the Styrofoam containers because they do not have enough plates; the food on the plates do not match the Meal Ticket because they do not have enough food, so they must substitute other foods. LVN A said several residents complain that they are not offered coffee in the morning, and she asked the kitchen staff, who told her there are not enough cups in the facility to offer residents their coffee. During an interview on 06/18/26 at 3:17 pm, CNA B indicated she often seen Residents #1, #2, #3, #4, and #5 offer their meals in Styrofoam containers, and they complained a lot about their meals being cold. During an interview on 06/18/26 at 3:25 pm, Staff C indicated she must use Styrofoam containers because there are not enough plates to serve residents their meals. Staff C said most of the residents received their food on plates. She stated it was difficult to keep the food hot, because the metal plate warmer under the plate was not hot. This was due to the two metal plate warmers in the kitchen not working and have not been working for the past two months. Staff C said the residents' bread for breakfast was not toasted, instead it's placed into a bag and onto the steam table, which could cause the bread to get wet and soggy. The bread was not toasted because the toaster has not worked for the past two months. Staff C said she has been asked to provide coffee to residents in the morning. She told the CNAs there were not enough coffee cups in the facility to do that. Observation on 06/18/26 at 3:35 pm of the kitchen revealed there was a commercial metal plate warmer in the storage attached to the kitchen that did not work, and there was metal plate warmer in the beverage area of the kitchen that did not work. During an interview on 06/18/26 at 4:20 pm, CNA D indicated daily for the past 2 months, 6 to 7 residents are offered their meals in Styrofoam containers. The residents included #1, #2, #3, #4, and #5 who complained that their food was cold, and they did not receive what was listed on the Meal Ticket. CNA D said she asked Staff C, who said they do not have enough plates and hot metal plates. CNA D said she asked the cook why the food does not match the Meal Ticket, and she said because they run out of food. CNA D said the residents have been complaining that they do not receive a cup of coffee, and she asked Staff C who said it was because they do not have enough coffee cups. Review on 06/22/26, the facility's breakfast menu dated 06/22/26 included the following:*Assorted Juice*Cereal of Choice*Sausage Patty*Scrambled Egg,*Breakfast Bread of Choice,*Margarine,*Jelly,*Milk*Beverage During an interview on 06/22/26 at 9:10 am, Staff E indicated the facility does not have enough coffee cups to give to every resident that wants coffee. Today, 06/22/26, Staff E said he took all the coffee cups they had in the facility and divided them into four halls, which meant each hall can only receive eight cups of coffee. During an interview 06/22/26 at 9:1 am, ADON G said he observed all the plates were covered with Saran wrap and most of them did have the hot metal plate to keep the food hot; and some plates that had the hot metal plate were cold to the touch. ADON G said this morning the kitchen staff did not have access to the Meal Tickets, because the facility does not have a Dietary Food Service Manager, and nobody could print them. Instead, the facility used the Diet Type Report that was printed and then cut into thin strips of paper, that identified the resident's name, location (room number), allergies, diet type, texture, fluid consistency, diet supplement and additional directions. She stated the likes and dislikes were not noted. These tickets were placed on the trays belonging to residents with special diets. The Trays without a Meal Ticket belonged to residents with regular diets. ADON G directed CNA C to pass out the regular diet trays to the residents. Observation and confidential interview on 06/22/26 at 9:15 am, Resident #1 was offered his meal tray, and he pointed out there were no condiments, no coffee, no orange juice, and no milk. Resident #1 said he needs his milk to mix into his Cream of Wheat, which he will not eat today because it's too thick. Resident #1 said his bread was not toasted, it was old, stale, and yellow. This bread is always like this, and he will not eat it. His eggs and sausage patty were cold because they did not use a hot metal plate holder, instead they wrapped his plate with saran wrap which does not keep his food hot or warm. Resident #1 indicated in the past he has received the plastic that goes underneath the metal plate. This plastic had foil over it, and his food was placed on top of the foil and his food was cold. He became upset and asked unknow nurse or CNA why he did not have a plate, and they told him it was because the facility was short of plates. Resident #1 said the following items were not offered from the breakfast menu: *Assorted Juice,*Breakfast Bread of Choice, 1 slice of bread*Margarine,*Milk*Beverage.Further interview with Resident #1 revealed he did not receive a beverage until he asked for his water cup be used for his coffee, since he was not given a cup of coffee. Observation on 06/22/26 at 9:20 am, R#1 did not have a Meal Ticket on his tray. During a confidential interview on 06/22/26 at 9:28 am, Resident #2 said she wanted her milk and juice. She then tried a piece of sausage with gravy, and she shook her head and said it was too spicy and cold and refused to eat any more food. Observation of Resident #2's breakfast tray on 06/22/26 at 9: 28 am, revealed the following breakfast items were not offered:*Assorted Juice, was not offered*Margarine, was not offered*Milk,*Beverage.Further observation revealed the slice of bread was not toasted and it was soggy. During an interview on 06/19/26 at 2:47 pm, ST H indicated she assist with passing trays out to the residents, and the food was not on a plate, instead it was placed on top of a piece of foil that was wrapped on top of the plastic container that would normally hold the metal plate warmer. During a confidential interview on 06/22/26 AT 9:25 am, Resident #4 indicated her breakfast was disappointing again, because her toast was wet, mushy, stale, yellow and not toasted. She had no butter, which you need for your toast, the sausage patty with red pepper flakes was too spicy, eggs were cold, Cream of Wheat should be hot, but it was not. Resident #4 said she has not had a hot meal in over two months. Resident #4 said she was not offered her orange juice, but was given 8 ounces of milk, which she does not like. When she was offered her plate, it had saran wrap to keep it warm, but it was cold. Resident #2 said in the past she was offered a Styrofoam container or a plastic container. This plastic container is for holding the metal plate inside of this plastic, instead they placed the plate with food inside this container. R#4 said, it does not matter what they do because the food is cold, and I'm tired of getting eggs, sausage, and Cream of Wheat that are cold. During an interview on 06/22/26 at 11:09 am, Staff I said when a tray does not have condiments it's because they have none in the kitchen. Staff I indicated the Food Service Manger left the facility 3 weeks ago and there has not been a Food Service Manager to take her place. Staff I said on the morning of 06/22/26 there was no butter to offer the residents, and the residents' bread could not be toasted because the toaster broke over two months ago. Instead, the bread was placed into a baggie, and onto a steamer, and this is what causes the bread to get wet and soggy. Staff I said this morning there were no Meal Tickets for the 06/22/26 morning meal, and this made it difficult to know what should go on a residents' meal tray, and if the wrong food texture was given to a resident, this could lead to a chocking incident. During an interview on 06/22/26 at 11:36 am, Staff J indicated the kitchen does not have a Food Service Manager, who quit 3 weeks ago, to print out the Meal Tickets for the morning meal on 06/22/26. The Meal Tickets are needed to ensure the resident receives the right food texture to prevent a chocking incident. Instead, she was provided with small strips of paper, which identified the resident's name, location (room number), allergies, diet type, texture, fluid consistency, diet supplement and additional directions. She stated the likes and dislikes were not noted and that was what she used to serve the food onto a resident's plate. Staff J said before she served the food onto the plates, she took the temperature of the foods, and hot food temperatures were taken and recorded between 190 to 200 F, which is where they should be before serving the food. She stated the food was served on a plate that cannot hold the temperature of the food, because the facility's metal plate warmers was not working. The layering of this plate required a plastic bottom that holds the metal plate warmer, the plate with food was placed on top of the metal plate, and then the plate was covered with a plastic cover. Staff J stated that should help keep the food warm until it was given to the residents. She stated if the metal plate was cold the food would be cold when it was given to the residents. Staff J stated the facility was short of plates and that was why 5 residents' food has been served in Styrofoam containers. Staff J said the sausage delivered to the facility was a spicy sausage and that's what she normally serves to the to the residents. Staff J said the toaster has not worked for the past two months, instead, the bread was placed in a small baggie, and set on the food warmer, and that was why they are wet and soggy. During an interview on 06/22/26 at 12:05 pm, Staff E indicated for the morning meal on 06/22/26 he was responsible for sending coffee to the 4 halls, he could only provide 8 cups per hallway because there was not enough cups. Staff E indicated the facility's 2 metal plate warmers and toaster were not working. Staff E stated on 06/22/26's morning meal, he did not add condiments to the meal trays because there was not a resident Meal Ticket to follow. During an interview on 06/22/26 at 2:13 pm, MD K indicated he was not informed the facility did not have working metal plate warmers to keep the plate of food warm from the kitchen to the resident. MD K said food that was not at the appropriate temperature can cause a resident to become ill. MD K said he was not informed that the facility's kitchen toaster was not working, and that they did not have enough plates to serve residents their meal, instead they were served on Styrofoam containers. Review of the facility's Key Aspects of Customer Service included Prompt Problem Resolution: Addressing any concerns or issues raised by resident or their families in a timely and efficient Manner is crucial. Promptly acknowledging and resolving problems helps build trust and shows that their satisfaction is a top priority. Review of the facility Food Preparation and Service policy and procedure dated that was undated, included Food Distribution means the processes involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portion for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas, etc. When meals are assembled in the kitchen and delivered to residents' rooms or dining area to be distributed, covering foods is appropriate, either individually or in a mobile food cart.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 meal (lunch meal on 6/10/2026) reviewed for meal accuracy, in that: 1. The facility failed to ensure the correct meal was served on 6/10/2026 according to the prepared menu for lunch for 108 residents. 2. The facility failed to ensure staff followed the correct weekly prepared menu. These failures could affect residents who received food from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss.The findings included: Observation on 6/10/2026 at 11:35 AM of the facility kitchen's dry pantry, freezer, and refrigerator revealed items in the dry pantry such as canned goods, breads, cereals, oatmeal, spices, and pasta. The freezer contained 2 cases of frozen fries, 1 case of corn, 1 case of zucchini, 3 cases of hamburger meat, 1 case of beef stew mix, 1 case of fish sticks, 1 case of egg omelets, 1 case of liquid eggs 1 case of broccoli. The refrigerator contained 2 cases of milk, 1 bag of shredded cheese, 2 boxed of diced potatoes, 1 case of sliced turkey lunch meat, 1/2 a case of ham lunch meat, 3 boxes of sliced cheese. During an interview on 6/10/2026 at 11:35 AM, [NAME] A stated they did not have a Dietary Manager, her last day was Friday 6/5/2026. She stated the lunch meal served on 6/10/2026 was pork chops, capri vegetables, mashed potatoes, fruit cobbler and a slice of white bread. She stated they did not follow the menu for the lunch meal. She stated the reason she did not serve the beef tator tot casserole, mixed vegetables, Texas toast, margarine, and summer fruit cup was because they were low on product and were not able to serve the meal listed on the menu. She stated when they sent the order to the supplier for the food, they got an email back that the facility was over budget and items were removed from the order. She stated they did not have enough tator tots for the casserole, so they made pork chops; they did not have mixed vegetables, so they made capri vegetables; they did not have the summer fruit cup, so they made fruit cobbler; and they served white bread in place of Texas toast. She stated it was difficult to follow the menu when items were removed from the food order. Record review of the facility menu dated week 3 revealed the lunch meal for 6/10/2026 as beef tator tot casserole, mixed vegetables, Texas toast, margarine, summer fruit cup. During an interview on 6/10/2026 at 12:05 PM, ADM B stated dietary staff should print the diet cards and they should match the menu. She stated that the supplier had the menu and should be able to see the food that was ordered matched the food to be served on the menu. She stated if there were issues with the food ordered staff should have discussed it with her. During an interview on 6/10/2026 at 2:20 PM, ADM C stated the dietary staff followed the wrong weekly menu. He stated they should have been on week 4 of the menu not week 3. He stated when dietary placed an order for food the food ordered should match the weekly menu. He stated dietary followed the wrong menu, so the items ordered did not match the menu and the supplier deleted the items and sent an email back to the facility dietary manager to let them know they were over budget. He stated the dietary manager could have gotten an override and ordered the food. He stated that the dietary staff should have been on week 4 and the lunch meal should have been cilantro lime chicken, rice pilaf, squash & red peppers, dinner roll, margarine, and mango chunks. He stated he would have the dietary manager from the sister facility place an emergency food supply order and get the dietary staff on the correct weekly menu for the evening meal. Record review of the facility menu dated week 4 revealed the lunch meal for 6/10/26 as cilantro lime chicken, rice pilaf, squash and red peppers, diner roll, margarine, mango chunks. Record review of the facility policy titled Menu Planning and dated 2023 revealed: Policy:Nutritional needs of individuals will be provided in accordance with the established national standards adjusted for age, gender, activity level and disability, through nourishing, well-balanced diets, unless contraindicated by medical needs. Based on a facility's reasonable efforts, menus should reflect the religious, culture, and ethnic needs of the population served, as well as input received from individuals and groups.Procedure:a. Regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. If menus are written in cycles they are rotated. Record review of the facility policy titled Standardized Recipes and dated 2023 revealed: Policy: Standardized recipes will be used when preparing menu items.5. Cooks/chefs should discuss problems or concerns about recipes with the director of food service and nutrition services so that issues can be resolved.

Based on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 2 (4/24/2026 and 4/25/2026) of 30 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours on 4/24/2026 and 4/25/2026.This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Record review RN time punches provided by facility undated for RN coverage revealed no RN hours for 4/24/2026 and 4/25/2026. During an interview on 5/06/2026 at 12:18 p.m. with ADM, she stated there was no RN coverage for 4/24/2026 and 4/25/2026. During an interview on 5/06/2026 at 01:53 p.m. with ADM, she stated the purpose of having an RN 8 hours a day was to provide nursing support and help with higher level of knowledge. She stated the staffing coordinator and the DON were responsible for scheduling RN coverage. She stated the staffing coordinator, and the DON had been trained in scheduling. She stated the potential negative outcome was that the facility was out of compliance and limited resources for the nursing staff. During an interview on 05/06/2026 at 02:01 p.m. with DON, she stated the staff coordinator and herself were responsible for scheduling nurses. She stated she was aware the RN scheduled on that weekend called off sick. She stated they were unable to find a replacement. She stated they do use agency for LVN nurses only. She stated she was not allowed to use agency for RN coverage. She stated the purpose of the RN was direct oversite care. She stated she had been trained on RN scheduling. She stated the potential negative outcome of not having an RN for 8 hours a day could be not having direct oversite care for the residents and staff. During an interview on 05/06/2026 at 02:40 p.m. with Staffing Coordinator, she stated she does not schedule the weekend RN supervisor. She stated they have two RN's who alternate weekends. She stated the weekend RN supervisors communicate with DON. She stated she was aware the RN called in sick but did not look for replacement. She stated she thought the DON would find replacement since the RN called in to the DON. She stated she had been trained in scheduling staff. She stated the potential negative outcome could be not having an RN to oversee the staff and not having extra help when needed. Record review of the policy provided by the facility titled, Staffing, Sufficient and Competent Nursing, revised 08/22 revealed the following: Policy Statement - Our facility provides sufficient number of nursing staff with the appropriate skills and competencies necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Policy and Implementation.3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on observation, interview and record review, the facility failed to provide food and drink that was palatable, attractive and at a safe and appetizing temperature for 5 residents (Residents #8, #60, #99, #101, and 1 confidential resident) reviewed for food palatability. one of one kitchen. A. Resident #8, #60, #99, #101 voiced concerned of cold food, flavor and/or texture.B. Nine of the 9 foods sampled on the meal tray were cold.C. One of the 9 foods sampled on the meal tray was mushy.D. Three of the 9 foods sampled on the meal tray had no flavor. E. Three of the 9 foods sampled on the meal tray were chunky. F. One of the 9 foods sampled on the meal tray was tough. These failures could result in a decline in residents' consumption of food and residents to have unwanted weight loss. The findings included: During an interview on 05/04/2026 at 2:37 PM, Resident #99 was asked how the food was and he responded by saying Some of them are not really good, no flavors, no taste. He stated that he ate at the dining. During an interview on 05/04/2026 at 2:49 PM, Resident #101 was asked how the food was and he stated, I almost choked once because I am on mechanical meals, that happened about a month ago, the food is not even warm, no taste and no flavor. He further added, I do eat in the dining and sometimes in my room. During a confidential interview a resident said, The eggs are very cold in the mornings, it doesn't taste good and no flavor, the lunch today tastes like an old food, the meat in particular. He stated that he ate in his room. During an interview on 05/04/2026 at 5:03 PM, Resident #60 was asked how the food tasted and he stated, The food is not good, doesn't look and taste good, sometimes it is cold. She further stated, I didn't eat the lunch today because the meat was tough, and I do eat in my room. During an interview on 05/04/2026 at 5:27 PM, Resident #8 was asked how the food was and she responded by saying Terrible for me, like sometimes the spaghetti wasn't drained enough, the food is blend, the food is cold most of the time and I do eat in my room, I did not eat the lunch because the vegetable wasn't drained well. During an observation on 05/04/2026 at 12:33 PM, the sample trays were delivered to the survey room. Sample tray findings found by the survey team and DM were the following: FOOD ITEMS Taste, Temperature, TextureRegular Potatoes ColdRegular Beef Cold/toughRegular Vegetables Cold/mushyMechanical Beef Cold/no flavorMechanical Potatoes Cold/no tasteMechanical Vegetables Cold/no tastePuree Vegetables Cold/hullsPuree Potatoes Cold/chunkyPuree Beef Cold/chunky During an interview on 05/06/2026 at 11:30 a.m., [NAME] A stated, I have worked here for two years now, that will be myself, the cooks and the DM that are responsible for monitoring of the food temperature, texture and flavor and why the meals were not palatable is, the cooks not cooking according to recipe. He stated, Honestly the steamtable doesn't get as hot as it is supposed to be, because it has been here for a while and I have received trainings on that, but have never seen the food palatability policy. He further stated that residents would get sick from such meals. During an interview on 05/06/2026 at 11:50 a.m., the DM stated, it was myself and the cooks' responsibilities for ensuring that all meals were palatable, though different people with different taste buds. She further stated, I think it is because we need plate warmers and probably not bad to upgrade the current steamtable, I have discussed with our previous maintenance and the ADM, the ADM agrees with me, but we have to follow up with the cooperate. She stated, no training yet, I got the food palatability policy but have not had time to look at it. She stated, Yes, I have few residents complained about the food, have discussed with them, reassured them that their concerns will be addressed. She stated serving such meals, the residents could get sick from not eating the food. During an interview on 05/06/2026 at 12:44 p.m., the ADM stated, that will be the cooks' responsibilities ensuring that all meals were palatable, while the DM reviews all that, and I don't have any idea or reason why the meals were cold, there is no reason why the meals shouldn't be palatable. She further stated, I am sure the kitchen staff have been trained on food palatability, but I have not come across such policy. She stated, Yes, we had some discussions regarding cold food, and we have been working on that, and residents could start experiencing weight loss from not eating such meals. During a telephone interview on 05/06/2026 at 1:27 p.m., the RD stated, I am no longer with the facility after 04/14/2026, and could not answer any of my questions, but aware that the facility is in a transition of getting a new RD for the month of May 2026. Record review of the facility's policy and procedure titled, Food Palatability, revised October 2017, reflected the following: Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation: Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued.

Based on interviews and record reviews, the facility failed to treat residents with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 9 confidential residents in that:The facility failed to ensure staff were not on their personal cell phones while providing care, which included assisting residents with their showers. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings include: At an undisclosed date and time nine confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. The nine confidential residents stated the use of cell phones by CNAs occurred on every shift. Confidential residents stated staff utilize their cell phones while performing showers, when performing care in resident rooms, and while supervising residents during supervised smoking times. The confidential residents stated the staff text and talk on their phones while walking down hallways, at the nurses' stations, and while performing care in their rooms. The nine residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage of the CNAs while performing care happened in the facility often, they said every CNA in the facility utilized their cell phone while performing care. During an interview on 05/06/26 at 2:15pm, the DON stated residents should be provided with privacy during resident care; the staff should provide residents with their full attention. She stated all staff were trained in privacy, resident rights, dignity, and cell phone usage during orientation and through continuous education by department heads and the DON. She stated staff were monitored by sporadic rounds completed by the DON and the ADM. She stated cell phones should never be used in patient care areas, cell phones should not be utilized anywhere Residents are visible. She stated the potential negative outcome could be residents feeling they are not important, staff could make a mistake while performing care, and a loss of dignity. During an interview on 5/06/2026 at 3:20pm, the ADM stated staff should provide residents with their undivided attention while performing care. The ADM stated all staff were trained in resident rights, dignity, and cell phone usage during the on boarding process, continuous online trainings, and in-services. She stated cell phones should only be used during breaks; personal calls were not allowed while staff were on the clock. She stated cell phones should be kept in the breakroom or staff vehicles. Staff were monitored for cell phone use by rounding completed by the ADM and the DON. The ADM stated the potential negative outcome for residents, if staff were using their cell phones, was residents could feel ignored, embarrassed, and suffer from a loss of their rights. Record review of the facility policy dated February 2021 titled Resident Rights revealed the following: Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and ImplementationFederal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a dignified existenceto be treated with respect, kindness, and dignityt. privacy and confidentiality

Based on observation, interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 5 of 33 residents ( Residents #30, #32, #93, #127, and #130) reviewed for resident rights . The facility failed to obtain signed informed consent based on information of the benefits, risks, and options available for Resident #30, #32, #93, #127, and #130 prior to administering psychotropic medication. These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the risk of the medications prescribed. Findings included: Resident #30 Record review of Resident #30's face sheet, dated 05/06/2026, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (blood vessel in the brain are blocked) and depression (mood disorder). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #30 was understood. The MDS revealed Resident #30 had a BIMS score of 13 which indicated the resident's cognition was cognitively intact. The MDS further revealed Resident #30 was taking antidepressant. Record review of a care plan for Resident #30 dated 03/11/2026 revealed a focus area for depression with interventions to administer medication. Record review of Resident #30's order summary report dated 05/06/2026 revealed the following orders: Duloxetine (depression) 30mg by mouth two times a day dated 02/06/2026Mirtazapine (antidepressant) 7.5mg by mouth at bedtime dated 02/06/2026 Record review of Resident #30's medication administration records dated 05/06/2026 for the month of May 2026 revealed resident received the following:Duloxetine 30mg twice a day on 05/01/2026 - 05/05/2026 and one time on 05/06/2026.Mirtazapine once a day at bedtime on 05/01/2026 -05/05/2026. Record review of Resident #30's electronic medical record scanned documents on 05/06/2026 revealed no consent for duloxetine or mirtazapine. Resident #32 Record review of Resident #32's face sheet, dated 05/06/2026, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia, depression (mood disorder) and anxiety. Record review of quarterly MDS assessment dated [DATE] revealed Resident #32 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #32 had a BIMS score of 03 which indicated the resident's cognition was severely cognitively impaired. The MDS further revealed Resident #32 was taking antidepressant. Record review of a care plan for Resident #32 dated 04/02/2026 revealed a focus area for depression with interventions to administer Paxil medication. Record review of Resident #32's order summary report dated 05/06/2026 revealed the following orders:Paxil (antidepressant) 10mg by mouth in the morning dated 04/22/2026. Record review of Resident #32's medication administration records dated 05/06/2026 for the month of May 2026 revealed resident received Paxil 10mg in the morning on 05/01/2026 - 05/06/2026. Record review of Resident #32's electronic medical record scanned documents on 05/06/2026 revealed no consent for Paxil. Resident #93 Record review of Resident #93's face sheet, dated 05/06/2026, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (blood vessel in the brain are blocked), depression (mood disorder) and anxiety (feeling of fear and worry). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #93 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #93 had a BIMS score of 05 which indicated the resident's cognition was severely impaired. The MDS further revealed Resident #93 was taking antianxiety and antidepressant. Record review of a care plan for Resident #93 dated 03/20/2026 revealed a focus area for depression with interventions to administer medication as ordered. The MDS further revealed a focus area for anxiety with interventions to administer medications. Record review of Resident #93's order summary report dated 05/06/2026 revealed the following orders:Buspirone (antianxiety) 10mg by mouth two times a day dated 02/17/2026.Citalopram (depression) 20mg by mouth in the morning dated 02/17/2026. Record review of Resident #93's medication administration records dated 05/06/2026 for the month of May 2026 revealed resident received the following:Buspirone 10mg twice a day on 05/01/2026 - 05/05/2026 and once on 05/06/2026.Citalopram 20mg by mouth in the morning on 05/01/2026 - 05/06/2026. Record review of Resident #93's electronic medical record scanned documents on 05/06/2026 revealed no consent for citalopram or buspirone. Resident #127 Record review of Resident #127's face sheet, dated 05/06/2026, revealed an 84 -year-old-female was admitted to the facility on [DATE] with diagnoses to include depression (mood disorder) and anxiety (feeling of fear and worry). Record review of electronic medical record revealed no completed MDS assessment. Record review of baseline care plan for Resident #127 dated 05/01/2026 revealed resident was able to understand and communicate with staff. Record review of Resident #127's order summary report dated 05/06/2026 revealed the following orders:Duloxetine (antidepressant) 20mg by mouth two times a day dated 05/01/2026. Record review of Resident #127's medication administration records dated 05/06/2026 for the month of May 2026 revealed resident received the following:Duloxetine 20mg by mouth two times a day on 05/01/2026 - 05/05/2026 and once on 05/06/2026. Record review of Resident #127's electronic medical record scanned documents on 05/06/2026 revealed no consent for duloxetine. Resident #130 Record review of Resident #130's face sheet, dated 05/06/2026, revealed a 64 -year-old-female was admitted to the facility on [DATE] with diagnoses to include depression (mood disorder) and anxiety (feeling of fear and worry). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #130 was understood. The MDS revealed Resident #130 had a BIMS score of 14 which indicated the resident's cognition was intact. The MDS further revealed Resident #130 was taking antianxiety and antidepressant. Record review of a care plan for Resident #130 dated 05/03/2026 revealed a focus area for depression with interventions to administer medication. The care plan further revealed a focus area for anxiety with interventions to administer medication. Record review of Resident #130's order summary report dated 05/06/2026 revealed the following orders:Clonazepam (antianxiety) 0.5mg by mouth three times a day dated 04/28/2026.Escitalopram (antidepressant) 10mg by mouth one time a day dated 04/28/2026.Wellbutrin (antidepressant) 150mg by mouth one time a day dated 04/28/2026. Record review of Resident #130's medication administration records dated 05/06/2026 for the month of May 2026 revealed resident received the following:Clonazepam 0.5mg by mouth three times a day on 05/01/2026 - 05/05/2026 and twice on 05/06/2026.Escitalopram 10mg by mouth one time a day on 05/01/2026 - 05/06/2026.Wellbutrin 150mg by mouth one time a day on 05/01/2026 - 05/06/2026. Record review of Resident #130's electronic medical record scanned documents on 05/06/2026 revealed no consent for clonazepam, escitalopram and Wellbutrin xl. During an interview on 05/06/2026 at 01:00 p.m. with DON, she stated the consents had not been signed. She stated the consents were up to date and then the ADM got sick, I left for a short time. She stated when she returned, she had no ADON's or staff and was having to work the floor. She stated consents were not kept up with. During an observation on 05/06/2026 at 01:00 p.m. of the folder provided by DON were unsigned psychotropic consents for Resident #30, #32, #93, #127, and #130. During an interview on 05/06/2026 at 01:53 p.m. the ADM stated the purpose of the psychotropic consents was to make residents aware of what medications they were taking and possible side effects. She stated she was not aware consents were not signed until today (05/06/2026). She stated nursing staff were responsible for obtaining consent when the order was received. She stated there was no reason why a consent would not be signed. She stated all nursing staff had been trained to get consent when medication was ordered. She stated the potential negative outcome could be unreported medication side effects. During an interview on 05/06/2026 at 02:10 p.m. the DON stated the purpose of the psychotropic consent was to make sure the resident knows what they were receiving. She stated the nurse was responsible for obtaining the consent when the order was received. She stated she was not aware consents were not obtained until today (05/06/2026). She stated the potential negative outcome could be the resident not knowing the adverse reaction. Record review of the facility's policy titled Psychotropic Medication Use, revised dated 07/2022 did not reveal any information related to medication consents. Requested policy on 05/08/2026 at 03:07 p.m. related to informed consent from ADM and DON and no policy provided.

Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 3 of 6 residents (Residents #1, 5, and 6) reviewed for advanced directives. The facility failed to ensure Residents #1, #5, and #6 who was listed as DNR (Do Not Resuscitate), had an Do Not Resuscitate form that did not have missed required information.These failures could place residents at risk of not having their end-of-life wishes honored and incomplete records. Findings include: Resident #1 Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Acute Kidney Failure (rapid loss of kidney function), and Type 2 Diabetes (high blood sugar). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #1's physician order summary, dated [DATE], reflected the following order: DNR-Do Not Resuscitate dated [DATE]. Record review of Resident #1's care plan, dated [DATE], reflected a care plan for DNR. Record review of Resident #1's DNR form dated [DATE] reflected the resident's signature was not dated, the physician did not print his name following his signature, the physician's signature was not dated, and the physician's license number was not present. Resident #5 Record review of Resident #5's, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included Traumatic Brain Injury (damage to the brain resulting from an external force. The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #5's physician order summary, dated [DATE], reflected the following order: DNR-Do Not Resuscitate dated [DATE]. Record review of Resident #5's care plan, dated [DATE], reflected a care plan for DNR. Record review of Resident #5's DNR form dated [DATE] reflected the DNR was missing a witnesses' signature. Resident #6 Record review of Resident #6's, undated, face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Alcohol Dependence (chronic disease characterized by a physical and psychological reliance on alcohol) and UTI (common bacteria caused by bacteria entering the urinary system). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #6's physician order summary, dated [DATE], reflected the following order: DNR-Do Not Resuscitate dated [DATE]. Record review of Resident #6's care plan, dated [DATE], reflected a care plan for DNR. Record review of Resident #6's DNR form dated [DATE] reflected the physician's signature was not dated. During an interview on [DATE] at 4:05pm with the SW, she stated the DNR was not valid if it was not filled out correctly. She stated she and the DON were responsible for ensuring DNRs were completed correctly. She verified missing information on DNR for Residents #1, #5, and #6. She stated there was no system for monitoring DNRs for accuracy. She stated the reason the DNR's were not complete was human error. She stated she was trained on DNRs. The SW stated the potential negative outcome for residents if a DNR was not completed correctly was the resident's end of life wishes may not be honored. During an interview on [DATE] at 4:25PM with the ADM, she stated the DNR was not valid if not filled out correctly. She stated the SW was responsible for making sure the DNR was completed accurately. She stated they did not have a system to monitor DNR for accuracy; however, her expectation would be the SW audits every DNR before uploading it into electronic records. She verified missing information on the DNR for Residents #1, #5, and #6. She stated she did not know why the information was missing. She stated the potential negative outcome was the residents may receive CPR when that was not their wish. She stated she was trained in how to complete DNR and her expectations were for them to be filled out completely and be correct. Record review of the Social Services Policies and Procedures Advanced Directives (Revised [DATE]) reflected the following: Advance Directives will be respected with state law and facility policy. Upon admission, the resident will be provided with information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital. The DNR orders will remain in effect until the resident or legal surrogate provides the facility with a signed and dated request to end the DNR order. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the residents wish to make changes in such directives. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes to clarify and adhere to the resident's wishes. Inquiries concerning do not resuscitate orders/requests should be referred to the administrator, director of nurses, or the social services director.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff, and the public, for 2 of 3 showers (Wildflower and Magnolia) and 2 of 12 rooms (rooms [ROOM NUMBERS]). The facility failed to ensure the Magnolia Shower had been repaired for approximately 4 months. The facility failed to ensure the showers in Magnolia and Wildflower units were held between water temperatures of 100-110 F degrees.The facility failed to ensure the bathroom sinks hot water in rooms [ROOM NUMBERS] were held between water temperatures of 100-110 F degrees.These failures could place residents at risk for lack of home-like environment and comfort. The findings include: During an interview on 5/4/2026 at 12:12pm with Resident #16, he stated the shower in the Magnolia unit had not been working for a while now and it was inconvenient. He stated they often had to get their showers in a different hall [Sunflower] further from their room and sometimes the water was not warm anymore because other residents had used the same shower. He stated he was not sure if they could use the Wildflower shower, but the hot water had been an issue throughout the facility. He stated he likes to shower as he was scheduled but because of the hot water issues, sometimes his showers were delayed. He stated he felt the facility did not take the hot water issues seriously. He stated he enjoyed his showers and would like the water to be consistently warm and the one on the Magnolia unit to be fixed. During an interview and observation on 5/4/2026 at 1:02pm with LVN A, she stated she had been at the facility since February 2026, and the Magnolia Shower had been out of order when she started at the facility. She stated she knew the previous maintenance supervisor had been working to fix it, but he was no longer at the facility. She stated the new MM A was working on the shower but was not sure when it would be fixed. Magnolia unit Shower door had an undated sign stating, DO NOT USE. During an interview on 5/4/2026 at 2:51pm with CNA B, she stated when she was assigned to the Magnolia unit, residents had to use the shower in Sunflower unit to shower. She stated she was not sure how long the shower in Magnolia had been out of order for. She stated sometimes the water did not get hot enough for all residents to get a hot shower and there were times showers were delayed because of that. She stated she was not sure if MM A was working on fixing it. During an interview and an observation on 5/4/2026 at 3:24pm with MM B, he stated he had been at the facility approximately 4 months and the shower in Magnolia Unit had been down for about the same time. He stated the previous maintenance supervisor had been looking into fixing it, but he was let go and MM B was an assistant. He stated MM A had looked at the shower to figure out what needed to be fixed but had not gotten around to it yet. He stated the water pressure was not sufficient enough for residents to shower with and the water temperature was not consistent. Observation of the Magnolia shower revealed the water did not have consistent pressure and the water trickled out of the handheld shower head. During an interview on 5/4/2026 at 3:35pm with MM A, he stated he had been at the facility for about 3 weeks and was trying to catch up on all the work that needed to be done. He stated he was not sure how long the Magnolia shower had been out of service, but he was aware it was not working. He stated the water pressure was really low and he needed a new cartridge to replace it but had not gotten around to doing so. He stated the hot water issues were not in the entire facility but were primarily on the Magnolia Hall rooms. He stated a plumber came out last week and were told they needed a new water heater. He stated he was not sure if that would fix the issue, but they would fix the identified issues and then re-assess. He stated the facility was working on getting bids (soliciting formal offers from contractors, vendors, or suppliers to perform work or provide services at a set price) to fix the issues identified by the plumber. He stated all the tankless water heaters were in one area and they traveled through the facility and it could take a while for hot water to reach those rooms. He stated he was aware of residents needing hot water in their rooms and showers to wash their hands, face and to feel comfortable.During observation on 5/4/2026 at 3:39pm in room [ROOM NUMBER], the hot water temperature was revealed to be 80.4 F . During an interview on 5/4/2026 at 3:41pm with Resident #95 she stated the water in her sink did not get hot enough and she would like to be able to wash her face and hands with warm water. She stated she had told the staff already but was not sure what was being done about it. During observation on 5/4/2026 at 3:42pm in room [ROOM NUMBER], the hot water temperature was revealed to be 76.4 F .During a confidential interview on 5/5/2026 at 1:45pm during resident council, 9 confidential residents stated the water did not get hot enough during their showers.During an observation on 5/5/2026 at 1:25pm of Wildflower Shower the hot water temperature was revealed to be 95.3 F . During an observation on 5/5/2026 at 4:37pm of Magnolia Shower, the hot water temperature was revealed to be 70.4 F .During an interview on 5/6/2026 at 10:38pm with the DON, she stated the shower in Magnolia Unit had stopped working approximately a month ago. She stated the hot water issues had begun on Magnolia Hall and have progressed to the other halls. She stated she was aware of the Magnolia shower not working and maintenance had been looking into it but was not sure what was wrong with the shower. She stated at this time the residents were able to shower in any available shower in the other units. She stated the importance of hot water, and a functioning shower was for residents to be comfortable, clean and to decrease the infection risk. During an interview on 5/6/2026 at 10:53am with the ADM, she stated she was not sure when the shower in Magnolia had stopped working. She stated when she began here at the facility, approximately mid-March, the previous maintenance supervisor had been working on it, but he was no longer employed at the facility. She stated new maintenance supervisor had not worked on the Magnolia shower yet, but they were addressing the hot water issues and the shower in Magnolia. She stated the hot water concerns had started last week and they had a plumber come out. She stated on 5/5/2026 the facility had approved the repair of the tankless water heater, and it would take about 2 days for the parts to come in. She stated the potential negative outcome of residents not having hot water for showers or in their rooms could be not feeling comfortable or having a homelike environment. Record review of facility documents titled Logbook Documentation between dates 1/05/2026-3/20/2026 revealed the following; Water TempsMagnolia [unit Rooms 200-216]:1/5/2026 - 1/09/2026: 93.6 F, 92.4 F , 93.7 F , 93.2 F ,96.7 F .1/12/2026 - 1/16/2026: 90.3 F ,93.2 F , 86.2 F , 83.4 F , 86.3 F .1/19/2026- 1/23/2026: 93.5 F , 96.5 F , 96.7 F , 95.2 F , 96.8 F .Comments: we are currently having a problem with out hot water return line losing pressure, after what we thought to be the problem, (the circulating pump) the problem is still there. Working with plumber to fix it.1/26/2026- 1/30/2026: n/a.2/02/2026 - 2/06/2026: 96.3 F , 98.4 F , 100.1 F , 97.2 F , 98.3 F 2/10/2026-2/09/2026: 93.5 F , 96.5 F , 91.2 F , 100.2 F , 89.6 F 2/16/2026-2/20/2026: 96.3 F , 98.5 F , 100.1 F , 99.3 F , 98.5 F 2/23/2026 - 2/27/2026: 86.3F , 89.6 F , 98.3 F , 96.5 F , 98.3 F 3/2/2026- 3/06/2026: n/a3/09/2026-3/13/2026: 96.8 F , 101.2 F , 100.1 F , 94.5 F , 96.3 F 3/16/2026-3/20/2026: 93.1 F , 83.7 F , 100.1 F , 98.3 F , 90.3 F Magnolia Shower:1/5/2026- 1/09/2026: 95.1 F , 99.6 F , 93.8 F ,95.4 F , 93.7 F .1/12/2026 - 3/20/2026: n/a. Water temperature documentation did not reveal the Wildflower shower to have temperatures below 100 F between 1/05/2026-3/20/2026. Record review of facility policy titled Maintenance Service dated 2001 revealed; 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. maintaining the building in good repair.I. providing routinely scheduled maintenance service to all areas. J. others that may become necessary or appropriate.Record review of facility policy titled Water Temperatures, Safety of dated 2001 revealed; 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110-115 F or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log.3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log.

Based on observation, interview, and record review, the facility failed to make information on how to file a grievance or complaint available to the residents for 9 of 9 confidential residents reviewed for grievances. The facility failed to ensure 9 of 9 residents were provided, through postings in prominent locations, the Grievance Procedure, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place residents at risk of unresolved grievances and decreased quality of life. Findings include: In Interviews at an undisclosed date and time, 9 of 9 confidential residents stated they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. The residents stated they did not know where to acquire a grievance form, who to turn the form into, and what happened once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Observations of prominent postings on 05/06/2026 at 2:35pm; the facility did not include instructions regarding the Grievance procedure with the prominent postings. Interview with the ADM on 05/06/2026 at 4:35pm; the ADM stated she was the Grievance Officer for the facility. The ADM stated the Grievance form was available on a shelf on the wall by the piano; she stated she did not know there were no forms available in the Grievance shelf. The ADM stated the Activities Director completed Grievance forms during monthly, resident council meetings when concerns were vocalized by Residents. The ADM stated staff also complete Grievance forms for some complaints that were discussed with them face to face with residents. The ADM stated she assigned grievances to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form, and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook for 3 plus years. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance. The ADM stated she would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council; the ADM agreed the availability of the Grievance forms, the Grievance procedure, and procedure for submitting a Grievance form anonymously should be explained to Residents at admission and continually discussed in monthly Resident Council meetings. Record Review of the Grievance policy on 04/28/2026 at 2:27pm; reflected a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Record Review of the Grievance Policy last updated in October 2017 reflected: Policy Statement:Staff members are encouraged to guide residents about where and how to file a grievance when the resident believes his or her rights have been violated. Policy Interpretation and Implementation: Staff members who overhear complaints or concerns from residents or their representatives should guide said person on how to file a grievance with the facility. The resident or their representative should be told they may file a grievance without fear of retaliation. The staff member will inform the resident or their representative where to obtain a form and inform them of the location of the written procedures for completing the grievance form.

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 in facility 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerator (x1), and freezer (x1), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the garbage can used for food waste was covered unless in use. 3) The facility failed to ensure the hair restraint was properly worn. 4) The facility failed to ensure the dish and pot washing area were clean. These failures could place residents at risk for food-borne illness and cross contamination.The findings included: During kitchen tour observations on 05/04/2026 that began at 9:34 a.m. and concluded at 10:15 a.m., revealed the following: -Garbage can, next to food prepping table, was uncovered and not in use. -Cook A, not properly wearing hair restraint to cover his mustache area. -Dirty black food residues under the pot & pan sink/draining area. Walk-in Freezer -What resembled chicken breasts (no label), hashbrowns, breast sticks, and sausages in different clear plastic bags, all with no use by date. Walk-in Refrigerator -What resembled lettuce, sausages, tortillas, and ground beef in different clear plastic bags, all with no use by date. During an interview on 05/06/2026 at 11:30 a.m., [NAME] A stated, I am responsible for putting the labels and dating (use by date) on all food items, as well as all other kitchen staff and whoever comes in on that shift is responsible for monitoring the labels and dating of all food items, since the DM assigned such task to us. He stated, I guess, I was in a hurry doing other kitchen tasks, forgetting to label and date all the food items, and I have been trained on labelling and dating of food items, equally seen both the food storage and kitchen sanitation policies. He stated, I forgot to wear the hair restraint properly, and the negative effects would be facial hairs falling into the food and residents could get sick. He further stated that the garbage can next to the food prepping table don't have lid that fits the can, and residents will get sick or giving them something that could cause some allergic reaction. During an interview on 05/06/2026 at 11:50 p.m., the DM stated, I am responsible for putting the date (use by date) and labelling of all food items alongside with the rest of the kitchen staff, and because of the busy nature of the kitchen, I forgot to do that. She stated, I have been trained on that and have come across food storage and kitchen policies, it would be me that is responsible for monitoring the dating and labelling of all the food items in the kitchen, the residents can get sick from such undated or unlabeled food items. She further stated that the garbage can, should have been covered when not in use, such failure could lead to food contamination. She stated, hair restraint needs to be wore properly, negative outcome would be hair in the food which could make the residents sick. On the dirty black food residues under the pot & pan draining area, she stated, Oh, that dirty food residues need to be cleaned, I don't have any reason why it was not cleaned and that might lead to black molds, which could result in residents falling sick. During an interview on 04/28/2026 at 12:44 p.m., the ADM stated, usually the cooks are responsible for dating and labelling of all food items in the kitchen, while the DM will be monitoring that task and added it would cause food borne diseases to the residents. She stated, because of the very busy nature of the kitchen, the kitchen staff forgot to label and date all the food items. She further stated that, the kitchen staff were all trained, again I want to say they have been here for a while and yes, I have seen both the food storage and kitchen sanitation policies. When asked about the open garbage can, the ADM stated, if not in use, then it should be covered, that is not allowed, and that will cause food contamination. On the dirty black food residues under the pot & pan draining area, she stated, Oh no, that is very unhealthy, the dirty food residues need to be cleaned, that could be part of their sanitation, that could cause food contamination due to bacteria growth. She further stated, [NAME] A should have been wearing the hair restraint properly, and hair in the food will not be good for the residents. During a phone interview on 05/06/2026 at 1:27 p.m., the RD stated, I am no longer with the facility after 04/14/2026, and could not answer any of my questions, but aware that the facility is in a transition of getting a new RD for the month of May 2026. Record review of the facility's policy and procedure titled, Food Preparation and Service, revised November 2022, reflected the following: Policy Statement: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: General GuidelinesIdentification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illnesses.Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.Food Preparation Area Areas for cleaning dishes and utensils are located in a separate area from the food service line to assure that a sanitary environment is maintained.Food distribution and Service8. Food and nutrition savvy stuff where hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Record review of the facility policy and procedure titled, Sanitation, revised November 2022, reflected the following: Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: Kitchen waste that are not disposed of by mechanical means are kept in clean, leak proof, nonabsorbent, tightly closed containers and disposed of daily. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (#1 and #2), in that: The door for dumpster #2 was left open.Garbage and debris in the vicinity of the 2 dumpsters. These failures could place residents at risk of exposure to germs and diseases carried by vermin and rodents.The findings included: Observation on 05/04/2026 at 10:21 a.m., revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial-size dumpster 3/4 full of garbage, with an open door (#2) and bags full of garbage on the floor around the dumpsters #1 and #2. During an interview on 05/06/2026 at 11:50 a.m., the DM stated, Everyone in the facility is responsible for keeping the dumpster area clean and closing the door, if you see a trash bag on the ground, pick it up and throw it into the dumpster. All staff members were responsible for monitoring such task. She further stated, I can't answer why the bags of garbage were on the floor because I don't know why. She stated, I have never had any training with my staff, because it was not brought to my attention. Such failure would accumulate a bunch of rodents, roaches, bugs and rats, which could travel into the building and could make residents sick from their droppings. During an interview on 05/06/2026 at 12:29 p.m., the MS stated, I am responsible alongside with my assistant for keeping the dumpster area clean and closing the door, equally responsible for monitoring of such task. It was something that we overlooked, it slipped my mind, was a hectic week. He further stated, no training yet, I am new and only been here for 3weeks and have not come across waste disposal policy. He stated, it could be a hazard for the residents that are mobile, especially those going near the dumpster area, as well would support bacteria growth. During an interview on 04/28/2026 at 12:44 p.m., the ADM stated, the maintenance personnels were responsible for keeping the dumpster area clean and closing the door, while the MS will be monitoring that task. She stated, no, I don't know why the dumpster area was littered with bags of garbage and not cleaned, and why the door was not closed. She further stated, I don't know if the staff have been trained and no, I have not come across waste disposal policy. She stated that, they could get rodents, insects, bugs and a collection of that, which would travel into the building, such could affect the resident's health. Record review of the facility policy and procedure titled, Sanitation, revised November 2022, reflected the following: Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #58 and Resident #29) reviewed for infection control. CNA D failed to utilize EBP and hand hygiene during foley catheter (a flexible, sterile tube inserted into the bladder to drain urine, held in place by an inflated balloon) care on Resident #58.CNA E failed to utilize glove change and hand hygiene during incontinence care on Resident #29. These failures could place residents at risk for cross contamination and infection. Findings included:Resident #58Record review of Resident #58 undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #58 had a medical diagnoses of cerebral infraction (a blockage (clot or plaque) reduces blood flow to the brain, causing tissue death) , obstructive and reflux uropathy (a blockage in the urinary tract that stops urine from flowing, causing it to back up into the kidneys), and benign prostatic hyperplasia with lower urinary tract symptoms (a common age-related, non-cancerous enlargement of the prostate gland).Record review of Resident #58s quarterly MDS dated [DATE] Section C- Cognitive Patterns revealed a BIMS score of 10 which indicated Resident #58 had moderate cognitive impairment. Section H-Bladder and Bowel revealed Resident #58 had an indwelling catheter (a flexible tube inserted into the bladder). Record review of Resident #58's care plan dated 3/14/2026 revealed EBP: Staff must use gown and gloves during high-contact resident care activities that could possibly to result in transfer of MDROs to hands and clothing of staff.interventions: Sign for EBP precautions will be outside resident's room, to alert staff of precautions, EBP: Staff must use gown and gloves during high-contact resident care activities.Record review of Resident #58's physician orders revealed foley cath [catheter] care q shift and PRN dated 4/22/2026. Physician order dated 5/04/2026 revealed Enhanced Barrier Precautions- gown and gloves required for high -contact activities: .providing hygiene.incontinence care.device care (catheter.). During an observation on 5/5/2026 at 2:18 pm, Resident #58 had an EBP sign on his door visible upon entering the room and a PPE box with gowns, mask and gloves was outside the room. CNA D entered Resident #58s room, washed her hands, put on a clean pair of gloves and unfastened Resident #58's brief. CNA D proceeded to clean Resident #58's foley catheter, scrotum and penis. CNA D turned resident onto his left side and removed the dirty brief. CNA D grabbed a clean brief from Resident #58's closet with dirty gloves. CNA D placed new brief below Resident #58. CNA D removed her gloves and washed her hands. CNA D failed to change her gloves and utilize hand hygiene during foley catheter care. CNA D failed to follow EBP precautions before and during Resident #58's foley catheter care by not wearing the appropriate PPE. During an interview on 5/5/2026 at 2:27pm, CNA D stated she did not know who the infection preventionist was. She stated she had been trained on infection control, hand hygiene and EBP but did not remember her last training. She stated she had not changed her gloves during the foley catheter care because she forgot. She stated she realized she had not utilized the appropriate PPE for EBP because it did not cross her mind. She stated the EBP was utilized to prevent the spread of infection and not using it could cause cross contamination. She stated the potential negative outcome of not changing gloves during foley care could be spreading infection. Resident #29 Record review of Resident #29's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #29 had diagnoses of dementia (a progressive, irreversible syndrome caused by brain diseases), muscle weakness (a reduced ability to exert force with muscle), and need for assistance with personal care. Record review of Resident #29s annual MDS dated [DATE] Section C- Cognitive patterns revealed a BIMS score of 03 which indicated Resident #29 had severe cognitive impairment. Section H- Bladder and bowel revealed resident #29 was always incontinence of bowel and bladder. Record review of Resident #29's care plan dated 4/07/2026 revealed [Resident#29] has incontinence.interventions: incontinent needs will be met.briefs, depends.when out of bed. During an observation of incontinence care on 5/5/2026 at 3:26pm, CNA E cleaned Resident #29's buttocks with wipes and removed the dirty brief from below Resident #29. CNA E grabbed a clean brief with dirty gloves and placed the clean brief on Resident #29. CNA E failed to change gloves and use hand hygiene before placing the clean brief. During an interview on 5/5/2026 at 3:34pm, CNA E stated her infection preventionist was the DON. She stated she was aware she needed to change her gloves when going from a dirty area to a clean area. She stated she must have forgotten to change her gloves before grabbing the clean brief. She stated she had been trained to change her gloves and use hand hygiene, and the potential negative outcome could be spreading infection. During an interview on 5/6/2026 at 10:32am with the DON, she stated she was the infection preventionist. She stated staff are trained on hand hygiene, gloves changes and EBP quarterly and infection control training is done monthly. She stated her expectation of staff was to follow all infection control policies including wearing a gown, gloves and mask for EBP. She stated a potential negative outcome of not following EBP and infection control practices could be spreading infection. She stated EBP are utilized for residents with a history of MDRO or any invasive devices. She stated she was not aware of staff not following EBP, glove changes or hand hygiene practices during incontinence care. During an interview on 5/6/2026 at 10:53am with the ADM, she stated the DON was the infection preventionist. She stated training on infection control, EBP, hand hygiene and glove changes is done through their online training program and periodically. She stated EBP is used for residents with invasive devices and history of MDRO's. She stated the potential negative outcome could be spreading infection. She stated her expectation was for staff to follow their infection control training and use the appropriate PPE and hand hygiene protocols. Record review of facility policy titled Enhanced Barrier Precautions dated 2001 revealed; Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include.providing hygiene.device care or use (.urinary catheter) .Record review of facility policy titled Perineal Care dated 2001 revealed; Purpose: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the residents skin condition.4. discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens/adult brief.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for respect and dignity.CNA C failed to provide privacy to Resident #1 when CNA C left Resident #1 naked in bed with the door open on 3/15/2026.This failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem. Findings include:Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #1 had a medical history of chronic kidney disease, malignant neoplasm of the spinal cord (a cancerous tumor arising within or spreading to the spine), and paraplegia (impairment of motor and sensory function in the lower half of the body).Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated Resident #1 was cognitively intact. Section GG- Functional abilities revealed Resident #1 was dependent on toileting hygiene requiring 2 or more helpers, and substantial assistance required for showers.Record review of Resident #1's care plan dated 3/20/2026 revealed [Resident #1] have impaired functional abilities r/t DX of Paraplegia. [Resident #1] require assistance with ADLs. Required assistance may vary. Some days/times may require more assistance than other. Usual performance Toilet Hygiene: Dependent Usual performance Personal Hygiene: Partial/moderate assistance Staff assistance: [times]1-2.Resident #3 (Resident #1's roommate)Record review of Resident #3's face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #3 had a medical history of gastroenteritis and colitis (colon inflammation), hypertension (high blood pressure) and paraplegia (impairment of motor and sensory function in the lower half of the body).Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated Resident #1 was cognitively intact.During an interview on 4/01/2026 at 10:45AM, Resident #3 stated he did remember the incident between Resident #1 and CNA C. He stated he was not sure what CNA C said but she had told him she couldn't give him a shower because she was doing rounds. He stated he did not know what time it was, but she did get him undressed in bed and then left. He stated Resident #1 was in bed naked and the door was left open. He stated he did not recall her yelling at Resident #1, only that she would do his shower later. He stated Resident #1 was saying stuff to her and CNA C walked out. Resident #3 stated he believed it was about 30 minutes before another nurse came to finish Resident #1's care.During an interview on 4/01/2026 at 10:58AM, Resident #1 stated that night he had gotten back to the facility late at approximately 11:30PM or 12:00AM on 3/14-3/15. He stated he had requested his bath but fell asleep after CNA C put him in bed. He stated when he woke up a few hours later at approximately 4:00AM he used his call light and CNA C came into his room. He stated he requested his shower from CNA C and she told him she was unable to do so at that time since she was in the middle of rounds. Resident #1 stated he was a little mouthy with CNA C and she took off his clothes and told him someone else would come into the room to give him his shower. He stated he had requested a shower because he did not want to wait until Tuesday for his next shower. He stated he was laying in bed for approximately 20 minutes until he called LVN D, a nurse from a different unit, and she showered him and got him cleaned up. He stated he did not usually have issues getting his showers, but he was not sure if something else was going on. He stated he did not feel embarrassed or humiliated but did not feel CNA C should have left him in bed naked. He stated he did not remember if the door was open or not. He stated this was the first time something like this had happened. He stated LVN D reported the incident to the DON, and it was immediately addressed. He stated he was happy with how quick the DON addressed it and was happy with the facility removing CNA C from his hall. He stated he was not sure if CNA C was still employed but he had not seen her.During an interview on 4/1/2026 at 1:45PM with CNA C, she stated she had been waiting for Resident #1 to get back from his pass to give him his shower. She stated when he requested his shower, at approximately 12:45AM she was in the middle of rounds and explained to Resident #1 she would lay him down and would come back to give him his shower. She stated Resident #1 stated I just want my fucking shower and she got him into bed. She stated he was cussing at her and saying, this is some bullshit. She stated she was attempting to complete Resident #1's incontinence care but Resident #1 had stopped cooperating with her and refused to turn for her and she was unable to complete his brief change at that time. She stated she told Resident #1 You know what, I am going to step out and someone else will come finish. CNA C stated she notified her charge nurse (LVN E) and did not return to the room the rest of the night because she did not want to make him more agitated. CNA C stated she had taken his bottoms off, and he was still wearing a shirt, and had half a brief on because he did not assist her in turning and she did not complete the care. She stated she was not sure if she did or did not leave the door open. She stated she did not cover him with a sheet before she left the room because he was cussing at her saying fuck this, fuck this bullshit. She stated she was not sure when someone else went in there or if his care was completed because she did not follow up. She stated a CNA from a different hall took over his room and they checked on him the rest of the night. She stated she felt she did the right thing by leaving because being in the room would make him more agitated. She stated she did not believe how she left Resident #1 in bed was a dignity concern. She stated she had been trained on de-escalation, and she did the right thing by stepping out and letting someone else step in. She stated she was suspended following the incident and had remained on suspension since then. She stated the incident occurred between 12:45AM- 1:15AM on 3/15/2026.During an interview on 4/1/2026 at 4:47PM with LVN D, she stated she received a call on the facility phone from Resident #1 on 3/15/2026 at approximately 3-4AM. She stated Resident #1 asked I know you're not my nurse, but can you come help me?. She stated she walked down to his room and the door was wide open, he was completely naked on the bed and the privacy curtain was not pulled between Resident #1 and Resident #3. She stated he had a bowel movement on his brief and dirty wipes on the bed. She stated she asked Resident #1 what happened and he explained CNA C had left him like that. She stated Resident #1 told her that CNA C had screamed at him and he had screamed back at her. She stated she got Resident #1 showered and cleaned up and went straight to the DON to report the incident. She stated she was not sure how long he had been left in bed like that, but it had not been long because Resident #1 mentioned CNA C had just laid him down. LVN D stated she was very irritated with the way Resident #1 was left and CNA C had not treated Resident #1 with respect or dignity. She stated CNA C should have at least provided privacy before leaving the room, if she felt she needed someone else to intervene, but she should not have left him exposed in that manner. She stated Resident #1 was calm with her and he did not appear to have any long-lasting changes to his behavior or emotional distress. She stated she felt Resident #1 was a little quieter for a few days following the incident, but he was back to himself. LVN D stated she attempted to speak to CNA C regarding the incident and CNA C told LVN D that Resident #1 was yelling at her and she (CNA C) was not going to take that, and walked away from LVN D.During an interview on 4/1/2026 at 5:32pm with LVN E, she stated she had not heard the interaction between CNA C and Resident #1 or if CNA C had yelled or not yelled at Resident #1. She stated CNA C had reported to her that Resident #1 had been cursing at her and she had stepped out to let him calm down. She stated CNA C never mentioned Resident #1 still required care or that he had been left in bed naked with no privacy curtain. LVN E stated she did not remember what time it was, but it was well past midnight when CNA C told her about Resident #1. She stated they had been trained to grab a second person or call for help if there is a resident who is yelling at them. She stated they had not been trained to leave the room if a resident is cussing at them, only to call for help. She stated after she learned of Resident #1's being left in bed naked with the door open, she agreed that it could be a violation of his dignity.During an interview on 4/2/2026 at 11:18 with the ADM, she stated she was the abuse coordinator. She stated she had not been the ADM at the time of the incident, but she had been made aware of the incident. She stated she expected staff to do all they can when they have to delay care to a resident by explaining what the plan would be and if the Resident was not cooperating, or if they refused care, she expected them to notify their charge nurse and the administrative team. She stated before staff leave any resident room, the resident should be in a dignified position, not exposed and they should be safe. She stated she would have expected CNA C to cover up Resident #1 and explained to Resident #1 that she would be going to get assistance. She stated CNA C should not have left him naked and exposed. She stated Resident #1 had not expressed any further concerns over the incident and he had been back to baseline. She stated the potential negative outcome of not treating residents with dignity and respect would be emotional distress, refusing care, or embarrassment. She stated they would be conducting rounds throughout the facility and ensuring all residents are being treated with respect and dignity, and if there are concerns, they would be addressing them at that time.During an interview on 4/2/2026 at 12:05pm with the DON, she stated training on resident rights was done with competencies, upon hire, and as needed. She stated her expectation of staff when any resident is being verbally aggressive is to excuse themselves but only if the resident is safe and needs are met. She stated staff are taught to treat residents how they would want to be treated. She stated she would have expected CNA C to use the call light and asked for assistance. She stated if CNA C had to step out, she should have provided privacy and dignity by covering Resident #1 with a blanket, close the privacy curtains and the doors before leaving the room. She stated CNA C should have been clear with LVN E and requested another aid to finish the care. The DON stated a potential negative outcome of not treating residents with respect and dignity could be emotional distress from being in an undignified manner. She stated the facility monitors compliance with respect and dignity by doing observation rounds, in-services, and re-enforcement of resident's rights.Record Review of facility policy titled Resident Rights last revised 2/2021, revealed; Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity. privacy and confidentiality;. perform services for the facility if he or she chooses or refuse to perform services for the facility.

Based on interviews and record reviews, the facility failed to ensure residents were free from abuse and/or neglect for 1 of 6 residents (Resident #1) reviewed for abuse and/or neglect.MM A told Resident #1 to get the fuck out of my face on 3/20/2026.This failure could cause residents emotional distress, a decrease in their health conditions, or exacerbation of their health conditions.Findings include:Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #1 had a medical history of chronic kidney disease, malignant neoplasm of the spinal cord (a cancerous tumor arising within or spreading to the spine), and paraplegia (impairment of motor and sensory function in the lower half of the body).Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated Resident #1 was cognitively intact.Resident #2Record review of Resident #2's face sheet revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #2 had a medical history of cerebral infarct (stroke caused by a blockage in brain blood), hemiplegia (a severe or total paralysis affecting one side of the body caused by brain damage), and epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures).Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated Resident #2 was cognitively intact.During an interview on 4/01/2026 at 10:58AM, Resident #1 stated he did not know what had happened between him and MM A on 3/202/2026. He stated they had always gotten along and there was not much to say about the situation because nothing had happened and he had not heard anything. He stated the DON had spoken to him about the incident, but he did not have any information because nothing had happened. He stated he only felt bad that MM A had been fired but that he had no other feeling towards the situation because he never heard MM A say anything to him. Resident #1 did not provide further details in regard to the incident.During an interview on 4/1/2026 at 1:37pm with MM A, he stated he had recently changed the codes to the exterior doors, and he had gone outside to smoke. He stated Resident #1 came over to him and had been antagonizing him about giving him the code to the door. He stated he explained to Resident #1 that he could not give him the code because he had to follow facility policy and not give the code out. He stated he attempted to defuse the situation a few times but Resident #1 kept egging on (means strongly encouraging, urging, or [NAME] someone to do something). He stated Resident #1 was stating he would tell others he got the door code from him (MM A) and it had upset him. He stated Resident #1 wasn't close to his face, but he stated, get the fuck out of my face. He stated he was frustrated and should have just walked away but he had become irritated at the situation. He stated he apologized to Resident #1. He stated Resident #1 was laughing with Resident #2 and did not appear upset. He stated he immediately reported himself to the DON. He stated Resident #1 and him do joke around at times, but he believed he had been having a bad day. He stated he was not sure if Resident #1 did or did not hear him because he did not say it loudly or in anger, but he was aware he said it and that is why he reported himself. He stated he had been trained on abuse and neglect, and his abuse coordinator was the ADM. He stated he did not feel that what he said was verbal abuse, but by definition it was and he followed his training. He stated he was immediately suspended and then fired.During an interview on 4/1/2026 at 3:00 pm with Resident #2, he stated he had heard MM A and Resident #1 bickering (argue about petty and trivial matters) back and forth. He stated he heard Resident #1 tell MM A that we would tell others that MM A gave him the code to the doors. He stated he then heard MM A tell Resident #1 get out of my face. He stated MM A did not cuss or yell just said, get out of my face. He stated Resident #1 was laughing and MM A walked away. He stated Resident #1 looked at him (Resident #2) and asked, what's his problem?. He stated himself (Resident #2) and Resident #1 were not upset and did not feel bad. He stated he did not believe MM A should have said it but that he did not hear him say fuck. During an interview on 4/1/2026 at 3:13pm with MM B, he stated he had been outside with MM A, Resident #1 and Resident #2 on 3/20/2026. He stated MM A and himself (MM B) had finished changing the door codes and Resident #1 approached MM A. He stated Resident #1 told MM A he already knew the code to the doors and would tell other people that MM A gave him the code. He stated MM A told Resident #1 no one will believe you but Resident #1 kept antagonizing MM A. He stated MM A got up and told Resident #1 Get the fuck out of my face and walked away. He stated Resident #1 did not appear upset and asked, what is wrong with him?. He stated he heard Resident #1 say he was just playing. MM B stated he had been trained on ANE, and his abuse coordinator was the ADM. He stated he felt that MM A's actions were verbal abuse.During an interview on 4/2/2026 at 11:18AM with the ADM, she stated she was the abuse coordinator. She stated she expects her staff to report ANE immediately. She stated if a resident is being intentionally verbally agitated toward staff, she expects the staff to walk away as long as the resident is safe and their needs are met. She stated when she spoke to MM A, she had expressed he should have just walked away and not replied to Resident #1's comments. She stated Resident #1 was not being mean, but he does like to push buttons (to deliberately annoy, irritate, or provoke a strong emotional reaction from someone). She stated MM A had been suspended and ultimately terminated following the incident. She stated a potential negative outcome of verbal abuse could be emotional distress and infringing on resident's rights.Record review of facility document titled Record of employee counseling dated 3/23/2026 revealed; Employee name [MM A].Detail of situations: Directed inappropriate and unprofessional language toward a resident by telling the resident get the fuck out of my face .Expectations/Outcome: Your actions are inconsistent with the expectation and policies outlined in the employee handbook and code of conduct, immediate termination is the result.Record review of facility policy titled Identifying Types of Abuse last revised September 2022 revealed, As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Abuse includes verbal abuse.Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication or sounds to residents within hearing distance, regardless of age, ability to comprehend or disability.

Based on interview, and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 7 residents reviewed for comprehensive care plans. The facility failed to revise Resident #1's care plan, a resident with an active Stage IV pressure ulcer, to reflect the use of a pressure-relieving mattress that was ordered by the physician on 11/8/25. This failure could place residents at risk for unclear staff guidance, inconsistent implementation of care, inadequate monitoring, delayed wound healing, and potential worsening or development of additional pressure injuries.Findings included:Record review of Resident #1's face sheet, dated 1/05/26, revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses to include central cord syndrome at unspecified level of cervical spinal cord (incomplete spinal cord injury) and quadriplegia (person with paralysis affecting all limbs and torso). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section I Active Diagnoses revealed Resident #1 had the following diagnosis:Quadriplegia Section M Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers (M0150) and he had no unhealed pressure ulcers(M0210). Resident #1's skin and ulcer injury treatments included a pressure reducing device for bed (M1200). Section V did reflect item 16 (Pressure Ulcer) as a triggered CAA and should be care planned. Record review of Resident #1's physician order, dated 1/5/26, revealed the following:Resident #1 had an order for a pressure reducing mattress to bed ordered 11/17/25 with a start date of 11/18/25.Resident #1 had a Pressure Ulcer, unstageable; Coccyx (Small triangular bone at the base of the spinal column) [cleanse with wound cleanser/ normal saline, pat dry, apply triad to wound bed, apply collagen, cover with superabsorbent dressing. Change daily and prn.] [Order dated 12/24/25 and Start date 12/25/25]Record review of Resident #1's admission assessment (Observation detail report), undated, revealed that Resident #1 had a pressure ulcer injury.Record review of Resident #1's wound risk assessment dated [DATE] revealed that Resident #1 had a pressure ulcer located on his coccyx. Record review of Resident #1's wound care clinic notes, dated 12/24/26, revealed the wound was present upon admission and was previously deteriorating but was currently stable.Record review of Resident #1's weight from PCC (electronic medical record software system) checked on 01/05/26 revealed that Resident #1 weighed 168 lbs as of 10/28/25. Record review of Resident #1's care plan, last revised 1/5/26 revealed the following:Resident #1 had a focus of wound management. Resident #1's goal for the focus area was his pressure ulcer would show signs of improvement and would be free from signs and symptoms of infection. Resident #1's interventions included the following: administer antibiotic therapy as prescribed, notify provider if there are no signs of improvement on current wound regimen and provide wound care per treatment order. Resident #1 had a focus that addressed him being resistive to care in regards to allow staff to reposition him due to his anxiety. Resident #1's goal for the focus area was Resident would cooperate with care. Resident #1's interventions included the following: educate Resident #1 and family of the possible outcome of not complying with treatment or care and to praise when the behavior was appropriate. Resident #1's care plan did not include the air-flow mattress, clear guidance for staff regarding implementation, monitoring, and expectations for pressure injury management.Record review of Resident #1's progress notes, dated 11/05/25-1/05/26, did not reveal any progress notes related to the pressure relieving air mattress, but did reveal the following regarding the pressure ulcer:LVN M documented on 10/16/25 at 4:18 PM the following: Resident #1 admitted to the facility for long term care. No skin integrity documentation was noted in the progress note.LVN N documented on 10/17/25 at 5:13 PM the following: Resident #1 complained of chest pain and shortness of breath.There was no progress note for the date Resident #1 returned. LVN N documented on 10/25/25 at 1:04 AM the following: Resident #1 transported back to the facility from the hospital on [DATE] at 6:45 PM with a stage 2 to coccyx.LVN O documented on 11/17/25 at 5:09 PM the following: Resident #1 noted with a decline in pressure injury to coccyx. Now presents as unstageable. Staff continues to educate and encourage him to allow them to turn and reposition him. Resident frequently chooses to lay on his back and refuses to offload pressure.LVN O documented on 11/20/25 at 1:51 PM the following: Resident #1 refused wound care after 2 attempts the NP was notified.LVN F documented on 11/20/25 at 8:00 PM the following: Resident #1 transported to the hospital for shortness of breath.There was no date for the day Resident #1 returned. The DON documented on 11/28/25 at 1:39 PM the following: Resident #1 order for his wound was Coccyx- Cleanse with NS, pat dry with 4x4 gauze, apply Calcium Alginate, cover with Super absorbent Silicone dressing, secure with Silicone tape. Change qod and prn and every day related to pressure ulcer of sacral region. The DON documented on 11/28/25 at 9:09 PM the following: Skin issue: Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. Wound is greater than 3 months. Signs and symptoms of infection: Nonhealing. Painful: Yes. Wound pain (Frequency): At dressing. Pain description: Aching. Pain description: Cramping. Pain description: Sharp. Wound pain interventions: Change in position. Wound pain interventions: Distraction techniques. Wound pain interventions: Relaxation techniques. Wound pain interventions: dressing change. Relief from interventions: Yes. LVN P documented on 12/03/25 at 10:34 AM the following: Resident #1 complained that he felt like he was crawling out of his skin Resident #1's vitals were checked all within normal limits. Resident #1 requested to go the hospital. Resident went to the hospital by his own request. No progress note to indicate Resident #1's return. LVN P documented on 12/06/25 at 4:40 AM the following: Resident #1 was admitted the hospital due to elevated troponin (protein found in the heart) levels.LVN F documented on 12/09/25 at 9:16 AM the following: Resident #1 arrived back to the facility. Head to toe assessment conducted. Resident #1 placed and the bed, positioned. Resident #1 continues to have open area to the coccyx. Resident #1 had a new order for Doxycycline 100 mg once a day for 7 days related to a UTI and infection in his wound. LVN F documented that the staff will continue to monitor Resident #1 for progress for worsening or improvement in his overall condition. LVN F documented on 12/10/25 at 3:42 AM the following: Resident #1 Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. Wound is greater than 3 months. Staged by: In-house nursing. ADON A documented on 12/10/25 at 9:55 AM the following: Resident #1 has an order for Mafenide Acetate External Cream 85 MG/GM Apply to coccyx topically in the morning related to pressure ulcer of sacral region. The Dietician documented on 12/12/25 at 92:27 PM the following: Skin: coccyx, PU stage 2, improving since 11/28/25.LVN F documented on 12/15/25 at 11:37 PM the following: Resident #1 Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. Wound is greater than 3 months. Staged by: In-house nursing.LVN F documented on 12/17/25 at 12:05 AM the following: Resident #1 Resident is Completely Immobile: does not make even slight changes in body or extremity position without assistance.LVN F documented on 12/18/25 at 12:09 PM the following: Resident #1 Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. Wound is greater than 3 months. Staged by: In-house nursing.The DON documented on 12/24/25 at 12:33 PM the following: Skin issue has been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure ulcer / injury. Unstageable ulcer due to other: Debridement occurred Wound was present on admission. Wound is greater than 3 months. Staged by: Health care provider. Length (cm): 8 Width (cm): 7.5 Depth (cm): 3 Exudate amount: Moderate. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Edema: No swelling or edema. Dressing appearance: Intact.ADON A documented on 12/30/25 at 4:14 PM the following: Resident #1 had a Change In Condition/s reported: Skin wound or ulcer Change in skin color or condition.LVN F documented on 12/30/25 at 11:02 AM the following: Resident on Clindamycin day 1 of 12 for coccyx wound infection. No adverse reactions noted at this time. Will continue to monitor for any changes or worsening in condition. Plan of care ongoing.The DON documented on 12/31/25 at 1:23 PM the following: Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer /injury. Pressure ulcer staging: Unstageable pressure ulcer / injury. Wound was present on admission. Wound is greater than 3 months. Staged by: Health care provider. Length (cm): 10.1 Width (cm): 11.2 Depth (cm): 4 Epithelial: 10%. Exudate amount: Moderate. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Odor after cleansing: Faint. Other: none. Edema: No swelling or edema. Dressing appearance: Intact. Additional care: Pressure reducing device for bed. Additional care: Turning / repositioning program. Additional care: Mattress with pump. Additional care: Pressure reducing device for chair.LVN F documented on 12/31/25 at 8:45 PM the following: Resident #1 on Clindamycin day 2 of 12 for coccyx wound infection. No adverse reactions noted at this time. Will continue to monitor for any changes or worsening in condition. Plan of care ongoing. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstageable pressure ulcer / injury. Wound was present on admission. Wound is greater than 3 months. Staged by: Health care provider.LVN F documented on 1/01/26 at 11:38 AM the following: Resident #1 on Clindamycin day 2 of 12 for coccyx wound infection. No adverse reactions noted at this time. Will continue to monitor for any changes or worsening in condition. Plan of care ongoing.LVN F documented on 1/03/26 at 9:36 PM the following: Resident #1 on Clindamycin day 2 of 12 for coccyx wound infection. No adverse reactions noted at this time. Will continue to monitor for any changes or worsening in condition. Plan of care ongoing.LVN F documented on 1/04/26 at 8:35 PM the following: Resident #1 on Clindamycin day 2 of 12 for coccyx wound infection. No adverse reactions noted at this time. Will continue to monitor for any changes or worsening in condition. Plan of care ongoing.An observation was made on 1/5/26 at 11:45 AM of Resident #1 lying in bed on a low-pressure airflow mattress. The large dial on the left side indicated it was set at 320. The normal pressure light was illuminated, and the static button was turned on.An observation was made on 1/6/26 at 11:26 AM of coccyx wound during wound care for Resident #1 with LVN L. Assisting LVN L to turn and reposition Resident #1 was the DON. Large coccyx wound observed with a small-moderate amount of slough (sluff or to shed something off) on the wound bed. Wound had slight odor, and drainage was noted to abd pad when dressing was removed. Resident tolerated wound care wo s/s of distress. During an interview on 1/5/26 at 11:45 AM, Resident #1 stated he had been having issues with his bed since he was admitted to the facility in October 2025. He stated that when he informed staff (names unknown), they appeared not to know what to do. He stated he never observed anyone checking his bed. He stated facility staff finally changed his bed after he and Family Representative E continued to complain about the bed. He did not specify the date. He stated he was afraid his wound could worsen if he was not on the correct bed. He stated he did not want to return to the hospital. He stated he was admitted to the facility with his wound. He stated staff did not appear to know what they were doing, and he was unsure whether they had been trained regarding his specific needs. He did not specify which needs that he felt staff were not trained on. During a confidential interview, they reported concerns regarding Resident #1's bed had been reported multiple times to facility staff (specific staff names unknown), including certified nurse aides and nurses. They stated they reported concerns that the bed was not properly inflated to the Social Worker and the DON. They stated they did not have exact dates for when concerns were reported. They stated the Social Worker informed them it was a nursing clinical issue and that she could not assist. They stated the bed was not properly inflated on multiple occasions. They stated they pressed on the mattress and were able to push it down to the bed frame. They stated they spoke with an agency nurse (name unknown) who did not have knowledge about the bed to provide assistance, but they expected the nurse to notify the appropriate person. They stated they did not know whether the issue was ever reported to facility management. They stated they were told the facility was changing ownership and that purchases could not be made. They stated they had concerns regarding whether staff knew how to manage Resident #1's bed due to the length of time it took for the bed to be replaced. They stated when they requested assistance, nurses and aides did not know how to fix the bed. They stated they did not know whether any lights were illuminated on the mattress control panel. They stated no facility staff could provide information about the low-pressure airflow mattress. They stated Resident #1 received a new bed in December 2025, and it had functioned properly since replacement.During an interview on 1/5/26 at 2:41 PM, CNA C stated nursing staff checked the low-pressure air mattresses. She stated she did not know what to look for regarding low-pressure air mattresses because certified nurse aides did not handle them.During an interview on 1/5/26 at 3:18 PM, CNA D stated all staff could check the mattress. She stated if an issue was reported, it was to be reported to the nurse in charge. She stated she did not know much about the low-pressure air mattress and had not received instruction regarding low-pressure air mattresses at the facility. She stated she did not know the mechanics of low-pressure air mattresses.During an interview on 1/5/26 at 3:18 PM, CMA S stated she recalled that Resident #1 was admitted to the facility with a pressure ulcer.During an interview on 1/5/26 at 3:48 PM, LVN Q stated she was an agency nurse. She stated she completed wound care for Resident #1 on this date. LVN Q stated Resident #1 was sometimes cooperative with wound care and repositioning.During an interview on 1/5/26 at 4:05 PM, the SW stated she did not have information regarding Resident #1's low-pressure air mattress. She stated Family Representative E had not expressed concerns about the mattress to her.During an interview on 1/5/26 at 7:20 PM, LVN F stated Resident #1's bed was replaced due to concerns that it was not inflating properly in the middle. She stated Resident #1 complained that he felt as though he was sitting on the rail. She stated she visually checked the bed to ensure it was inflated when she completed wound care. She stated Resident #1's wound care was done daily and as needed if he soiled his brief and it affected the wound dressing. She stated she was unaware whether other staff checked the bed when providing care. She stated the bed was replaced within one week of the concern being brought to facility staff's attention. She stated she did not complete wound care on the date of the interview with the HHSC investigator and was unaware of the condition of the bed at the time of the interview. She stated wound care was completed on the day shift majority of the time. She stated no one had reported issues with Resident #1's bed. She did not disclose details regarding how often staff should be checking the mattress or which setting the mattress should have been set. She did state Resident #1's wound was stable but it started to look worse after it had been debrided by the wound care provider. She did not have an exact date of when the procedure was completed but stated the wound remained smaller and the same size until debridement. She did not disclose who was responsible for checking the bed but stated anytime she was in the room she checked the bed by physically touching the mattress. During an interview on 1/5/26 at 7:47 PM, CNA G stated the Maintenance Supervisor was responsible for checking low-pressure airflow mattresses. She stated the ADM would also check them if needed. She stated she had not received instruction regarding low-pressure airflow mattresses and that staff were not provided individualized instruction regarding those mattresses.During an interview on 1/5/26 at 8:08 PM, CNA H stated Resident #1 had experienced issues with his bed at one time. She stated she did not know about the lights or indicators on the bed because staff had not been trained on the mechanics of the bed. She stated that on one occasion, on an unknown date, while changing Resident #1, she placed pillows under him and felt as though she could feel the bed frame. She stated she reported the concern to LVN F and assumed it was addressed, which was why she did not follow up. She stated she had not received individualized training regarding Resident #1's bed or what to monitor.During an interview on 1/5/26 at 8:27 PM, CNA I stated she had heard Resident #1 had problems with his bed but had not personally noticed any issues. She stated she did not check beds and assumed nurses checked them, but she was unsure. She stated staff had not received additional instruction regarding Resident #1's low-pressure mattress.The HHSC investigator attempted to contact MD J on 1/6/26 at 8:53 AM to discuss Resident #1's wound and the low-pressure air bed. He did not answer, and a message was left.The HHSC investigator attempted to contact NP K on 1/6/26 at 9:17 AM to discuss Resident #1's wound and the low-pressure air bed. He did not answer, and a message was left.During an interview on 1/6/26 at 9:36 AM, the DON stated Resident #1 was admitted to the facility from another facility with a wound to the coccyx. The DON stated Resident #1 was at the facility for 1-2 days before he was transferred to the hospital. The DON stated Resident #1 returned from the hospital with worsened wounds. The DON stated Resident #1 returned to the hospital at least 1 or 2 more times after his initial admission. The DON stated Resident #1 had received wound care services since admission and had received wound care supervision from NP R on a weekly basis. The DON stated Resident #1 was non-compliant with repositioning. The DON stated Resident #1 had been on an air mattress due to his coccyx wound since admission. The DON stated that on 12/16/25, Resident #1's wound culture revealed an infection, and he was currently taking antibiotics to address the infection.During an interview on 1/6/26 at 10:15 AM via telephone, the Vendor's Operations Manager stated low-pressure airflow beds could operate with the low-pressure light illuminated; however, the static light should not be illuminated. He stated if the static light was on, it indicated the bed had no movement and would attempt to inflate further. He stated the bed was designed to operate with the center of the mattress slightly softer and that the head of the bed should not remain in a constant upright or 90-degree position. He stated the bed was functioning at full capacity when it was plugged in and turned on. He stated the head of the bed was at the correct angle, which he identified as 45 degrees or less. He stated if the head of the bed exceeded 45 degrees, the resident could feel uncomfortable and perceive the bed as deflated. He stated the instruction regarding maintaining the head of the bed at 45 degrees or less was not included in the manufacturer's manual and was communicated verbally by technicians when asked. He stated this was one of the issues associated with low-pressure airflow mattresses. He stated having the head of the bed elevated greater than 45 degrees while in static mode could cause pinching in the mattress, preventing full inflation. He stated there was no indication on the bed to measure the degree and that staff would have to use their best judgement to measure the angle. He stated technicians often delivered the bed without providing further instruction. He stated he did not know whether instructions for bed operation were provided to facility staff. He stated the bed not being used as intended could negatively affect a resident's pressure ulcer and that other beds were recommended for pressure ulcer management. During an interview on 1/6/26 at 11:27 AM, the MDS Coordinator stated a care plan was used as a guide for all staff who worked at the facility to know what was going on with each resident. She stated the care plan included the residents' ADLs, active issues/conditions such as pressure ulcers, and any preferences. She stated interventions should also be included, as the interventions were the expectations so that staff could care for the residents properly. She stated if all interventions were not included in the care plan, there could be a negative outcome and the resident could be placed at risk for decline. She stated she was unaware that Resident #1's low-pressure air mattress was not care planned, and the potential reason it was not care planned was because they no longer had a designated wound care nurse. She stated in the past it would have been the wound care nurse's responsibility to ensure the information was placed in the resident's care plan. She stated the system to monitor care plans to ensure that all information, including interventions, was placed in the resident's care plan was that a baseline care plan was completed within 48 hours of admission. She stated care plans were then discussed during morning meetings. She stated the wound nurse would update them on wounds and inform them if there were new wounds, healed wounds, or changes in the condition of existing wounds. She stated the wound nurse would then ensure that all interventions were placed in the resident's care plan. She stated if additional meetings were needed, those would be scheduled. She stated she as the MDS Coordinator ensured that all CAAs were care planned with their interventions and goals. She stated the ADONs ensured that acute items were care planned. She stated all department heads were responsible for goals and interventions related to their departments. The MDS Coordinator stated that the use of the low-pressure air mattress should have been care planned as an intervention in Resident #1's care plan. She stated she had been trained on the facility's expectations and policies for care plans and that they reviewed those expectations frequently. She stated she expected all care plans to be reviewed to ensure nothing was missing. She stated if anything was identified as missing, it should be added and all appropriate parties should be notified. The MDS Coordinator stated that since the facility no longer had a wound care nurse, no discussions had occurred regarding who would take over those duties related to care plans. She stated the former wound care nurse would have been responsible for entering the low-pressure airflow mattress information. She stated she was unsure how long the facility had been without a wound care nurse. She stated overall, as a team, they were all responsible for ensuring resident care plans were revised and included all necessary information, including goals and interventions. The MDS Coordinator stated she did not know specific information about low-pressure airflow beds but believed staff would need to know all relevant information about the beds in order for them to function at the highest effectiveness for the resident.During an interview on 1/6/26 at 12:22 PM, ADON B stated the care plan was a plan that all clinical staff used to ensure staff were doing what they needed to do to keep residents safe. He stated, for example, if a resident had behaviors, the resident would have interventions to assist in keeping the resident safe. He stated they would want a general outcome to be positive and to correlate with the interventions. He stated the use of the low-pressure air mattress should have been care planned. He stated he was unaware that the use of a low-pressure air mattress for Resident #1 had not been care planned and did not have a reason why it was not care planned. He stated the potential negative outcome for not care planning the use of the low-pressure air mattress was that if the mattress was low, the resident could acquire pressure ulcers or wounds in the facility, which could be dangerous. He stated he was unsure of the facility's system for monitoring and ensuring care plans included all required information and were revised accordingly. He stated that, based on his experience, the MDS Coordinator would have been responsible for ensuring interventions such as the use of a low-pressure air mattress were care planned. He stated in his past experience the MDS Coordinator was usually particular about residents' care plans. He stated he had been trained on the facility's policy and expectations regarding care plans. He stated the facility was in the process of changing EMR systems. He stated he expected care plans to read almost like a biography and that the information in the care plan should be accurate to keep residents safe. He stated all wounds were not the same and all low-pressure airflow mattresses were not the same. He stated processes and troubleshooting could differ depending on the bed. He stated everyone in Administration was responsible for ensuring all interventions were entered into resident care plans. He stated the MDS Coordinator would be the key essential person responsible for resident care plans. He stated he had not been specifically trained on low-pressure airflow mattresses at the facility but had general knowledge that the low-pressure light should not be illuminated and that the head of the mattress should remain above 30 degrees.During an interview on 1/6/26 at 12:39 PM, ADON A stated she had not been trained and had not received information regarding the specifics of low-pressure airflow mattresses. She stated she had not received training on ensuring the air mattresses were functioning properly. She stated a care plan was a plan that established care for each resident. She stated it included goals for the resident and interventions to address any problems the resident may have. She stated low-pressure airflow mattresses were implemented to help offload pressure and assist residents with pressure sores. She stated the potential negative outcome of staff not having information regarding low-pressure airflow mattresses was that staff may not know how the bed functioned. She stated low-pressure airflow mattresses were used to treat and prevent pressure ulcers. She stated she had not been in her role very long (since November 2025) and could not state whether the low-pressure airflow mattress should have been care planned for Resident #1. She stated she had not been trained on care plans due to being pulled to the floor because of short staffing. She stated she was unsure whether residents had the same type of air mattress and assumed differences in mattresses would affect what staff needed to know. She stated she did not have an answer regarding how staff were trained on the differences and expectations related to low-pressure airflow mattresses. She stated Resident #1 admitted with a pressure ulcer. She stated she was unsure whether the low-pressure airflow mattress was implemented upon admission or afterward. She stated she was unaware that Resident #1's low-pressure airflow mattress had not been care planned and did not have a reason why it was not care planned. She stated she was unfamiliar with the facility's system for monitoring resident care plans. She stated she had started training but was pulled to the floor shortly thereafter. She stated she believed the MDS Coordinator would have been responsible for resident care plans.During an interview on 1/6/26 at 12:56 PM, the DON stated that regarding the low-pressure airflow bed, the expectation was that the dial should be set to the resident's weight. She stated the static light should never be illuminated unless indicated by a physician's order or at the resident's request. She stated if the static light was illuminated and would not turn off, it indicated the bed needed maintenance. She stated nursing staff had been trained on the expectations for low-pressure airflow mattresses. She stated her training documentation would only include nurses' signatures because they were responsible for checking the function of the low-pressure airflow bed. She stated she would provide a copy of the training; however, the training was not provided prior to investigator exit. She stated she did not have a specific policy for low-pressure airflow mattresses. She stated all wounds and treatments were not the same and should be treated differently and individualized. She stated Resident #1 admitted to the facility with a pressure ulcer and the low-pressure airflow bed intervention was implemented upon admission. She stated she was unaware that Resident #1's care plan did not include the low-pressure airflow mattress intervention. She stated the potential negative outcome for not care planning the intervention was that it could result in an increase in infection or worsening wounds. She stated the purpose of the low-pressure airflow mattress was to prevent pressure ulcers. She stated the system to monitor resident care plans was that care plans were reviewed quarterly, upon admission, and whenever there was a change in condition. She stated overall she and the MDS Coordinator were responsible for ensuring all applicable interventions were included. She stated the care plan should have reflected the implementation of the low-pressure airflow bed at admission. She stated the charge nurse at admission would also have been responsible. She stated the reason the low-pressure airflow bed may not have been care planned was because the facility was transitioning companies.During an interview on 1/6/26 at 1:25 PM, the ADM stated he was unaware of the logistics related to the low-pressure airflow bed, but staff were aware of the logistics and expectations. He stated he could not state in detail what the care plan should include because it had been some time since he received in-depth training on care plans. He stated the care plan was what staff, specifically direct care staff, used to guide how residents were cared for. He stated interventions such as the use of a low-pressure airflow mattress were expected to be care planned. He stated residents did not all have the same type of mattress and that mattress selection was based on acuity. He stated all resident pressure ulcers and wounds were treated differently based on physician's orders. He stated Resident #1 admitted with a pressure ulcer. He stated without reviewing the EMR, he could not confirm whether the low-pressure airflow mattress was implemented upon admission or

Based on observation, interview and record review, the facility failed to follow their own established smoking policy for 1 of 7 residents reviewed for smoking. (Resident #1)The facility failed to ensure Resident #1 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) at his bedside. This failure could place residents at risk of injury or harm.Findings included:Record review of Resident #1's face sheet undated indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinsons (brain disorder), anxiety (feeling of fear and worry), hypertension (high blood pressure) and weakness.Record review of Resident #1's annual MDS assessment dated [DATE], indicated he had a BIMS score of 14, which indicated he had intact cognition. The MDS indicated Resident #1 was independent or needed set-up/clean-up assistance for most ADLs. The MDS indicated Resident #1 was using tobacco at the time of the assessment.Record review of Resident #1's Care Plan Report dated 09/12/25 indicated he enjoys smoking at times. The goal was Resident #1 will keep all cigarettes and lighters locked at the nurse's station and will only smoke during scheduled smoke times with a staff member present. Record review of Resident #1's Safe Smoking assessment dated [DATE] indicated Resident #1 had demonstrated the ability to safely smoke with other interventions - needs a staff with him to monitor him. During an observation and interview on 11/15/25 at 11:50 am with Resident #1, revealed he was lying in bed with headphones on. An observation revealed there were no smoking supplies seen on bedside table, nightstand or sink counter. Resident #1 stated that he was a current smoker. He stated he did have cigarettes and lighter in his room. He stated he kept his cigarettes and lighter in the black bag on his walker. Observation revealed the walker with black bag was in the room by the sink. He stated he walked to the smoking area to smoke. He stated there were certain smoking times during the day and staff were always present when he smoked. He stated he only went to smoke during smoking times. He stated he was not told he could not keep smoking supplies in his room. He stated he only kept them in his black bag on his walker. During an observation on 11/15/25 at 12:05 pm revealed Resident #1 went to his walker and unzipped the black bag on the walker. Observed in the black bag there was one cigarette pack and one lighter. Resident #1 zipped the bag closed and placed the walker in front of the sink area in the room. During an observation on 11/15/25 at 01:40 pm revealed residents outside in the smoking area smoking. MA A was supervising the residents. Observed a blue smoking supply box sitting on the ground beside MA A. Resident #1 was sitting in a chair smoking with his walker in front of him. During an interview on 11/15/25 at 01:42 pm with the DON, she stated per the smoking policy residents were not allowed to have smoking supplies in their room. She stated she had received training on the smoking policy, and all staff had been trained on the facility smoking policy. She stated she was not aware Resident #1 had smoking supplies in his room. She stated she had not seen any smoking supplies in residents' rooms. She stated she expected staff to follow the smoking schedule and go out with residents to smoke. She stated the purpose of the smoking policy was to keep all residents safe. She stated the potential negative outcome could be a resident starting a fire. During an interview on 11/15/25 at 01:50 pm with MA A, she stated she did not normally supervise residents while smoking but the other staff were busy with resident care. She stated Resident #1 had his cigarettes in his black bag on walker. She stated she had been trained on the smoking policy. She stated Residents were not allowed to keep smoking supplies in room or on person. She stated she did not take smoking supplies from the resident. She stated she had not reported the incident to the ADM or the charge nurse because she had just come in from supervising the residents. During an interview on 11/15/25 at 02:30 pm with the ADM, he stated per the facility policy residents were not allowed to have smoking supplies in their rooms. He stated, I cannot search their room and keep them from going to the store next door. He stated the smoking policy was changing from the old company to the new company. The ADM looked at the smoking policy provided by the DON and stated Yes, that is the new one. He stated the convenience store was so close that the residents signed themselves out and got what they wanted. He stated, I cannot police all that. He stated he was not aware of any residents with smoking supplies in their rooms. He stated he was not aware Resident #1 had smoking supplies in his room. He stated Resident #1 was aware of the smoking policy and items not allowed in resident rooms. He stated no one had reported to him seeing smoking supplies in resident's room. He stated SW kept Resident #1 cigarettes in her office locked up because he bought seven cartons at one time. He stated he was not sure if he got a pack from SW or what. He stated residents were told on admission that smoking supplies cannot be kept in room. He stated smoking supplies were kept in a blue tackle box and the box goes from each station based on the smoking time. He stated the majority of the staff had been trained on the smoking policy. He stated the potential negative outcomes could be smoking in room, starting fires and if there was oxygen in the room the residents could blow themselves up. During an interview on 11/15/25 at 02:45 pm with the SW, she stated smoking was an issue at the facility because residents went to the store next door and purchased smoking supplies without the facility knowing. She stated they were not allowed to go through residents' belongings. She stated Resident #1 did not go to the store but would have other residents purchase items for him. She stated Resident #1 did a spend down (money spent) of his financial account and bought 14 cartons of cigarettes at one time and she kept them locked in her office. She stated Resident #1 would come by her office and request cigarettes and she would open and pack and print his name on top and place them in the blue smoking box. She stated she was not aware Resident #1 had smoking supplies in his room. She stated she had received training on the smoking policy and residents were not to have smoking supplies in the room. She stated if they saw smoking supplies in a resident room the smoking supplies need to be removed. She stated all current smoking residents had smoking assessments and were safe to smoke alone but it was the facility policy that residents were to be supervised while smoking. She stated the potential negative outcome could be a resident lighting a cigarette in room or causing a fire. Record review of the facility' policy titled Smoking Policy - Resident dated October 2022 reflected the following: Policy Statement - This facility shall establish and maintain safe resident smoking practices.Policy Interpretation and Implementation.14. Residents may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 19 of 22 confidential residents. The facility failed on 03/07/2025 to ensure 19 of 22 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews and Record Review during Resident Council on, 03/06/2025 at 10:30am, 19 of 22 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Nineteen Residents attended the meeting, the 19 Residents in attendance had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy on 3/07/2025 at 2:33pm; according to the facilities' Grievance policy a copy of the Grievance/Complaint procedure should be posted in a prominent location. Observed prominent postings on 3/07/2025 at 3:17pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. Interview with the ADM on 3/07/2025 at 1:35pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and assign them to department heads. The ADM stated the Grievance form was kept at the Nurses' Station and in the ADM's office. The ADM stated the Residents cannot obtain a Grievance form without asking the ADM or the SW for the form. The ADM stated staff completed Grievance forms for Residents, Residents do not ask for forms and complete them on their own. The ADM stated there was no procedure for Residents to submit Grievances anonymously. The ADM stated the facility has 72 hours to resolve Grievances once they were submitted. The ADM stated he assigned the Grievance to the appropriate department, that department addresses the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated he will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure and it was not being discussed in Resident Council. Grievance Policy Record Review of the Grievance Policy last updated in 2023. Policy Statement: All grievances filed with the facility will be investigated and corrective actions will be taken to resolve the grievance. Policy Interpretation and Implementation: 1. The facility will make available information on how to file a grievance available to residents, family, and staff. 2. The Administrator or designed will assign the responsibility of investigating the grievance. 3. Each Resident grievance form will include the date and time and details of the grievance. 4. The Administrator or designee will record and maintain all grievances in the Grievance Log. 5. The Resident Grievance form will be filed with the Administrator or designee and the resolution will be identified within three working days of the concern. 6. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 3 working days of the filing of the grievance. 7. If during the investigation abuse, neglect, misappropriation and/or injuries of unknown source are identified, the facility will refer to the Abuse Policy. a. Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and b. Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievances for period of no less than 3 years from the issuance of the grievance decision.

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents (including elopements) for one (Residents #1) of four residents reviewed for elopements.in that: The facility neglected to replace Resident #1's wander guard after he cut it off and failed to monitor the wander guard's placement per the facility's elopement protocol and the physician's order, which resulted in Resident #1 wandering away from the facility undetected at approximately 2 A.M. in 43-degree weather. The facility failed to implement elopement procedures after an exit door's alarm was activated, which resulted in staff not being aware Resident #1 left the facility. There was no search for Resident #1. Staff did not know he was missing until he was returned to the facility after being found by the police. It was determined a past non-compliance Immediate Jeopardy (IJ) existed from 2/14/22 through 02/17/22. This IJ was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The actions included in-servicing the staff on elopement procedures, direct the night CNA to sit at a chair near resident's room, placing a Roam Alert bracelet on Resident #1, and updating the Elopement book stored at the nurses' station. On 02/17/22 QAPI met and implemented the following: ensure Resident #1, per his eMAR, was wearing his wander guard 24 hours a day 7 days a week, test his wander guard daily to ensure it was working, and discharge Resident #1 to a secure unit for his safety (he was discharged on [DATE]. The failure could place residents at risk for physical or psychological harm or injury. Record review of Resident #1's Face Sheet indicated he was a [AGE] year-old male, who was admitted to the facility on [DATE]. This report included his diagnosis as a skin wound to his left and right upper arms, a balloon-like bulge in the artery that carries blood from the heart, thickening of blood vessels from the heart, lung disease, wearing down of protective tissues at the end of the bones, blood clot in the vein, loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities, history of falling, hallucinations, muscle weakness, difficulty walking, and lack of coordination. Record review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] indicated he scored an 8 on his Brief Interview for Mental Status, which indicated his cognition was moderately impaired. Resident #1's Functional Status indicated he required setup with supervision for walking in his room and corridor and locomotion on and off the unit. Record review of Resident #1's Care Plan with start dated 02/08/22 and revised on 02/14/22 indicated his wander guard would be monitored to ensure it was in place. This plan indicated Resident #1 required supervision and setup for ambulation and transfers. Record review of Elopement Evaluation report dated 10/28/21 indicate Resident #1 was ambulatory, cognitively impaired, poor decision-making skills, and/or pertinent diagnosis (Example, dementia, hallucinations, etc.,) displays behavior that indicate an attempt to leave, body language, etc., indicating an elopement may be forthcoming. This report indicated Resident #1 scored a 60 revealing he was at risk for elopement. This report included if the resident is at risk for elopement, continue with elopement protocol and interventions (i.e., interview resident, family, staff monitoring, 1:1 supervision, 15-minute checks, place a wander guard) and document all interventions. Record review of Resident #1's Physician Orders dated 10/28/21 and current as of February 2022 indicated a wander guard should be applied to Resident #1 for safety related to wandering and/or elopement seeking every shift, day, evening, and night; verify wander guard placement every shift, day 6 a.m. - 2 p.m., evening 2 p.m. - 10 p.m., and night 10 p.m. to 6 a.m., and wear wander guard at all times every shift, day evening and night. The February 2022 eMAr reflected the wander guard was not available on the 10 a.m. to 10 p.m. shift from 02/01/22 through 02/15/22. Record review of Resident #1's eMAR dated 01/01/22 - 01/30/22 included an order to ensure the wander guard function was tested on ce per day and was documented as follows: 01/04/22 not administered because he was not available, and he refused 01/04/22 - 01/07/22 - 01/11/22 - 01/14/22, 01/17/22 - 01/21/22, and 01/24/22 - 01/28/22. And the eMAR dated 02/01/22 - 02/15/22 indicated the wander guard was not administered because item was not available on 02/01/22 - 02/04/22, 02/01/07 - 02/11/14, and 02/14/22 - 02/15/22. Record review of Resident #1's eMAR dated 01/01/22 - 01/30/22 included an order to apply wander guard to resident for safety related to wandering and/or elopement seeking and was documented as follows: 01/01/22 not administer - out, 01/02/22 not administer- resident unavailable, and he refused 01/04/22 - 01/07/22, 01/10/22 - 01/14/22, 01/17/22 - 01/21/22, and 01/24/22 - 01/28/22. And the eMAR dated 02/01/22 - 02/15/22 indicated the wander guard was not available 02/01/22 - 02/04/22, 02/07/22 - 02/11/22, and - 02/14/22 - 02/15/22. Record review of Resident #1's eMAR dated 01/01/22 - 01/30/22 included an order to always wear wander guard and was document as follows: 01/01/22- resident unavailable, 01/01/22/evening - resident out, 01/02/22/night - resident unavailable, and he refused 01/04/22 - 01/07/22, 01/10/22 - 01/14/22, 01/17/22 - 01/21/22, and 01/24/22 - 01/28/22. And the report dated 02/01/22 - 02/15/22 indicated it was not administered because it was not available on 02/01/22 - 02/15/22. And the eMAR dated 02/01/22 - 02/15/22 indicated the wander was not administered/unavailable on 02/01/22 - 02/04/22, 02/07/22 - 02/11/22, and 02/14/22- 02/15/22. Record review of Resident #1's eMAR dated 01/01/22 - 01/30/22 included an order to verify placement every shift and was documented as follows: 01/01/22 evening and night - out or unavailable, and refused 01/04/22 -1/07/22, 01/10/22 - 01/14/22, 01/17/22 - 01/21/22, and 01/24/22 01/28/11. And the eMAR dated 02/01/22 - 02/15/22 indicated it was not administered on 02/01/22 day, evening, and night, and 02/02/22 - 02/04/22, 02/07/22 - 02/11/22, and 02/14/22- 02/15/22. Record review of Resident #1's Progress Note dated 02/14/22 at 2:52 a.m. indicated Resident #1 was returned to the facility by Family Member A, who said she was notified by the police (report not filed) that Resident #1 was wandering around trying to get to Family Member A's home. Resident #1 said he could not remember how he got out of the facility. Resident #1 was found at the convenience store. This note included the option of Resident #1 having a wander guard and Family Member A agreed and indicated someone would call her to review papers needed to sign for the wander guard. Record review of Resident #1's Progress Note dated 10/28/21 at 12:00 p.m. LVN E indicated Resident #1 was noted to possibly be an elopement risk due to ambulating without assistance and going to doors and looking outside. Nurse Practitioner (NP #1) was notified, and a new order was received for a wander guard, which was applied to the right wrist. (Resident #1 was not wearing a wander guard prior to 10/28/21). Record review of Resident #1's Progress Note dated 10/28/21 at 9:07 p.m. LVN G indicated Resident #1's cut his off his wander guard bracelet off his wrist. Record review of Resident #1's Progress Note dated 10/29/21 at 1:48 p.m. LVN E indicated wander guard was reapplied to Resident #1's left wrist and he said he would leave it on as long as it didn't bother him. Record review of Resident #1's Progress Note dated 11/01/21 at 5:15 a.m. LVN F indicated there was an error on the eMAR, due to Resident #1 not having a wander guard on his left wrist. Record review of Resident #1's Progress Noted dated 11/15/21 SW A indicated Resident #1 was forgetful. Observation on 02/15/22 at 6 p.m. of the facility's exterior area revealed the North to South street located in front of the facility was a heavily travel street. Observation on 02/15/22 at 11:49 p.m. indicated there was a chair in the hallway near Resident #1's room, and CNA H was walking around the same area. During an interview with CNA H on 02/15/22 at 11:49 p.m. indicated she was directed to sit on the chair near Resident #1's room, because he had eloped from the facility. CNA H indicated on her shift and in the past Resident #1 had made no attempts to leave the facility. CNA H was directed to monitor and keep a close eye on Resident #1 through out her shift. Record review of Navigation Maps revealed the convenience store was approximately .2 miles from the facility. Record review of Time and Date past weather for the local area indicated on 02/14/22 the temperature was 43 degrees. During an interview with Resident #1 on 02/15/22 at 12:50 p.m., indicated when he left the facility (02/14/22 at 2 a.m.) he was asleep on his recliner and the next he remembered was standing in front of the guy at the store. Resident #1 could not recall why he left the facility, which door he used to exit the facility, he could not recall hearing an alarm when he opened the door. Resident #1 said he called Family Member A with his personal phone, because when he tried to take a taxi to her house, he only had fifty dollars, and he was not going to pay anybody that much money. Resident #1 said the police officers showed up and talked to Family Member A, who arrived at the store to pick him up and return him to the facility. Resident #1 indicated he was not intentionally leaving the facility; he just woke up from his recliner and then was in the store and cannot recall how he got to the store. Resident #1 said he used to wear a plastic band on his wrist (wander guard), but he cut it off with his pocketknife. Afterwards, the staff took his pocketknife, and since then he has not worn the wrist band, nor did he have it on when he left the facility. Resident #1 was not sure how the wrist band works or what it's purpose. Observation on 02/15/22 at 12:50 p.m. Resident #1 was not wearing a wander guard. During an interview with LVN E on 02/15/22 at 9:20 a.m. indicated Resident #1 did not have was not wearing a wander guard on 02/15/22 at 10:59 a.m. and 10:12 a.m. because he refused even after she explained the importance of wearing a wander guard. LVN E on 02/15/22 at 1:59 p.m. indicated Resident #1 agreed to wear the wander guard, which she applied, after she talked him into wearing one. During an interview with Family Member A on 02/16/22 at 1:09 p.m. indicated on 02/14/22 at approximately 2:00 a.m., she received a phone call from Resident #1, who said he was handing his cell phone to this guy, but nobody was on the phone. Afterwards, Family Member A called Resident #1 and he answered the call and handed the phone to the police officer. The officer indicated Resident #1 was at the convenience store and asked if he had memory problems. Family Member A replied that Resident #1 at times does have memory problems, she assured the officer she would pick him up from the store immediately. Family Member A met Resident #1 at the store, where he told her he recalled waking up and then walking into the store. Family Member A said Resident #1, who was wearing a light jacket, was cold due to the temperature being 40 degrees Fahrenheit. Family Member A indicated towards the end of October 2021 (10/28/21), Resident #1 was found outside of the West exit door, after an unknown person assisted him outside. After this incident, Resident #1 was ordered a wander guard bracelet; however, he was not wearing one on 02/14/22 at 2 a.m. Family Member A indicated she wants Resident #1 to wear the wader guard to ensure his safety. During an interview with LVN A on 02/15/22 at 2:26 p.m. indicated she was working on 02/14/22 at approximately 2 a.m. when she heard the facility's North door's doorbell chime and saw an older man and a woman attempting to enter the facility. LVN A opened the door and that's when Family Member A informed her the police had reported to her Resident #1 was at the convenience store. She said Family Member A told her Resident #1 was attempting to get a taxi to take him to her (Family Member A's) house, but he could not remember her address. Resident #1, Family Member A, and LVN A went to Resident 1's room where LVN A assessed Resident #1, who had no visible injuries, and he was not wearing a wander guard. LVN A indicated Resident #1 said he could not recall how he left the facility. LVN A said, prior to Resident #1 and Family Member A returning to the facility, she was unaware Resident #1 was missing nor was she informed the West exit door's alarm had been activated and chiming. After Resident #1 returned to the facility, LVN B informed LVN A that CNA A informed her she heard an alarm and though it was a resident's concentrator that was chiming. That's when CNA A searched for the alarm that led her to the West exit door, where the alarm was chiming, she did not see anybody nearby, so she put the code into the keypad to stop the door alarm from chiming (sounding). LVN A indicated she worked with LVNs B and C, and CNAs, A, B, C, and D on 02/14/22 on the 10 p.m. to 6 a.m. shift; however, none of these staff reported to her the West door's alarm was activated and chiming. If she had been notified, she would have conducted a head count of her residents and alerted staff that a resident was missing, so they could implement elopement procedures. LVN A indicated she asked LVN B to assist with monitoring the West exit door to ensure Resident #1 did not exit the building. LVN A indicated she was familiar with elopement procedures but not familiar with what the color code (code pink). LVN A indicated in the past Resident #1 exited through the West exit door with the assistance of a visitor, but she escorted him back into the facility. LVN A said she did not see Resident #1 leave the facility, nor did she hear the West exit door's alarm chime, because she cares for residents in two areas of the facility. LVN A cared for residents in rooms 206 to 216 (Resident #1's room was #206) and then walked past station 2's dining area, a nurses' station, where LVN B was caring for residents in rooms 300 to 320, and through a set of closed double doors to care for residents in rooms 20 through 32. And LVN A had CNA B assigned to care for residents in rooms 206 to 216, which included Resident #1. During an interview with LVN A on 03/01/22 at 1:25 p.m., indicated she marked a Y on Resident #1's eMAR, indicating he had his wander guard on; however, she clarified he did not have one on and she had marked Y instead of N, by mistake. LVN A said Resident #1 did not have a wander guard before he left the facility and after he returned to the facility. During an interview with CNA A on 02/15/22 at 10:30 p.m., indicated on 02/14/22, after her break, at approximately 2 a.m. she sat in the dining area when she heard an alarm, and thought it was a resident's oxygen concentrator alarm, she got up go locate the concentrator that was alarming. CNA A located the chiming sound coming from the alarm at the front West exit door, that's when and she put the code into the keypad and the chiming turned off. CNA A looked around the door area and did not see anybody, she looked through the lobby's windows and did not see anyone outside. CNA A notified CNA B, who cares for Resident #1, that the door's alarm was chiming, that's when they pushed on the push bar and the alarm did not activate and chime, they concluded the alarm had a glitch. CNA A indicated she reported the alarm to her charge nurse, LVN B, who suspected someone tried to enter the building and caused the alarm to activate. After discussing it with LVN B they thought maybe the alarm had a glitch due to the contractors using it during the day. CNA A indicated the oxygen concentrator's alarm chime was very similar to the door's alarm, that's why it took her a few minutes to locate the chiming. CNA A indicated she was directed by LVN B to assist with monitoring the West exit door, approximately once an hour, to ensure Resident #1 did not exit the building. Since this incident, CNA A was in-serviced on elopement procedures, and informed not to deactivate the facility's exit doors' alarm, instead to report to her charge that a door alarm was activated. During an interview with LVN B on 02/15/22 at 10:57 p.m., indicated on 02/14/22 at approximately 2 a.m. CNA A informed her that she heard an alarm and that's when she went out to look for the noise thinking it was an oxygen concentrator, but she found the chiming was coming from the facility's West exit door. LVN B indicated CNA A looked around the area of the West exit door and did not see anybody, so she put the code into the keypad and the alarm turned off. Afterwards, LVN B conducted a head count of her residents and they were all accounted for and she did not inform LVN A that the door alarm went off. LVN B thought CNA A had informed LVN A, who cares for Resident #1, that the West exit door's alarm was activated and chiming, and to her knowledge nobody left the building. LVN B said she was sitting at the nurses' station when she saw a tall gentleman with a hat and a lady pass by her nurses' station and go towards rooms 206 - 216. LVN A informed LVN B, the couple was Resident #1 and Family Member A, who was notified by the police that Resident #1 was at the store without anybody's knowledge. LVN B was informed by LVN A that she assessed Resident #1 and noted no injuries. LVN B indicated she was asked by LVN A to assist with monitoring the West exit door, approximately once per hour, to ensure Resident #1 did not exit the building. LVN B indicated a code pink was not activated because to her knowledge nobody was missing. LVN B did not see Resident #1 exit the building through the West exit door where the alarm was activated and chimed. LVN B indicated LVN A and CNA B were responsible for Resident #1. LVN B confirmed the oxygen's concentrator's alarm chime sounded like the West exit door's alarm chime. LVN B said she was caring for 37 residents on station 2 in rooms 40 - 61; however, LVN A cares for residents in rooms 20-32 and must go past the dining area, LVN B's nurses' station, residents' rooms 40 - 48, and a set of closed double doors to care for residents in rooms' 206 to 216. LVN B indicated she was in-serviced on elopement procedures. During an interview with CNA B on 02/16/22 at 2:17 p.m., indicated he was caring for the residents in rooms 206 to 216, including Resident #1, and saw him in his room sleeping on his recliner on 02/14/22 at 12 a.m. CNA B said he heard a door alarm and saw CNA A checking for the sound because she though it was an oxygen concentrator. CNA B said CNA A returned and informed him the sound was coming from the West exit door, where she checked the area, saw nobody in the area. CNA B indicated CNA A did not go outside to check because she was not sure anybody had left the facility. CNA B said he did not report that the West exit door alarm was activated and chimed and was turned off with a code to his charge nurse, LVN A. CNA B indicated he thought the door had a glitch and that was what caused the door's alarm to activate and chime. CNA B found out Resident #1 was missing when Resident #1 and Family Member A returned him to the facility. CNA B indicated he was asked by LVN A to keep a close eye on Resident #1's to ensure his whereabouts and monitor the West exit door, approximately once per hour, to ensure Resident #1 did not exit the building. CNA B was in-serviced on elopement procedures and informed not to deactivate the facility's exit doors' alarm, instead to report to her charge that a door alarm was activated. During an interview with Maintenance Supervisor (MS A) on 02/15/22 at 5:15 p.m. confirmed and demonstrated the push alarm will chime if the bar is pushed. If the push bar is held for 15 seconds, it will release the locking mechanism and will continue to chime until the code is put into the keypad. While the alarm was chiming, MS A walked towards the nurses' station near rooms 206 to 216, where LVN E and CNA E were standing in front of room #211. LVN E and CNA E said they could not hear the door chime that was ringing from the West exit door. Afterwards, LVN E activated an oxygen concentrator's alarm, which sound very similar to the West exit door, as confirmed by MS A. In addition, MS A demonstrated the wander guard sensors to ensure they would chime if a resident with a wander guard got to close to an exit door. During an interview with MS on 03/01/22 at 3:01 p.m., indicated that on 02/17/22 he left a message with Company A requesting they address the facility's exit door alarms by increasing the sound, and ensuring a wander guard sensos was installed at a nurses' station 3. Twelve days later, MS A conducted a follow-up call to Company A, and was directed to call Company B for repairs. MS A contacted Company B and was told that due to an outstanding balance of 6037.00, accrued from three previous visits, they would not address repairs needed at the facility until they were paid. MS A indicated he had a wander guard but was not asked by staff to provide one for Resident #1, before he eloped from the facility on 02/14/22. MS A, who is responsible for ordering and issuing wander guards, was asked for a wander guard for Resident #1 on 02/14/22 at approximately 12 p.m. and 15 seconds later, he gave the nurse a wander guard. During an interview with ADON on 02/17/22 at 9:49 p.m., who reviewed and provided eMAR reports, indicated Resident #1's check off list for February 2022 noted on 02/13/22 on the 10 pm to 6 am shift, he was checked off as wearing his wander guard; however, 02/07/22, 02/08/22, 02/09/22, and 02/11/22 the spaces were left blank. ADON indicated Resident #1's nurses would have left the spaces blank if he was not wearing his wander guard. During an interview with MDS Coordinator on 02/17/22 at 10:42 a.m. indicated Resident #1's Care Plan included wearing a wander guard with start date 02/08/22 and revised 02/14/22. MDS Coordinator said she did not revise the care plan to address Resident #1 removing or not wearing his wander guard because she was not informed. MDS Coordinator confirmed reviewed Resident #1's Progress Note dated 10/28/22 indicated Resident #1 cut off his wander guard and then it was reapplied. Record review of the facility's undated floor plan indicated the area between Resident #1's room, Room #206, to the West exit door, included seven empty rooms, an empty nurses' station, double doors that lead into a foyer, and a second set of double doors that open to the exterior area of the facility's parking lot. Resident #1's room was caddy corner from where the North to South hallway meets with the East to West hallway. The East to West hallway had eight rooms with residents, and Resident #1's room was approximately 6 rooms from the nurses' station. This floor plan indicated the area between room 206 to rooms 20 through 32 included 10 resident rooms, closed double doors to go into Station 2 dining area and rooms 40 through 48 and go through closed double doors to go into rooms 20 through 32. During an interview with the DON on 02/17/22 at 10:42 a.m. confirmed Resident #1 had a physician's order dated 10/28/21 to wear a wander guard, which had had not been discontinued. DON confirmed Resident #1's Care Plan should have been revised to include Resident #1 cut his wander guard off and being noncompliant with wearing his wander guard. During an interview with Administrator on 02/17/22 at 12:55 p.m. indicated when the door alarm was activated, the nurses should have been informed, a head count should have been conducted, and if a resident was missing, a code pink (used to notify staff of a missing resident) should have been initiated to include a search of the interior and exterior areas of the facility. Since the incident involving Resident #1, staff took action to monitor the exit doors upon his return to the facility. In addition, the wander guard was applied to Resident #1's wrist, staff were in-serviced on elopement procedures, monitoring of eMAR to ensure appropriate documentation, and Elopement report was updated. In addition, the QAPI committee on 02/17/22 concluded Resident #1, for his safety, would be discharged to a secure unit. On 02/24/22 Resident #1 was discharged from the facility to a secured unit. During an interview with Nurse Practitioner A on 02/17/22 at 11:18 p.m. indicated Resident #1, prior to leaving the facility on 02/14/22 at 2 a.m., should have been wearing a wander guard for his safety as ordered. On 03/01/2 at 6:25 p.m. the Administrator was given the opportunity to provide a policy addressing wander guards, but he was unable to locate a policy. Record review of facility's Emergency Procedure - Missing Resident Revised December 2021, indicated Resident elopement resulting in a missing resident is considered a center emergency. 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. 2. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. Emergency Procedures - Missing Resident included announcing Code Pink report to nursing station to see if the resident has signed out, notify the Administrator, Director of Maintenance, and Director of Nursing, activate a recall roster, and report to resident unit for instructions. Afterwards, staff should initiate a thorough search of the facility, grounds, and neighboring streets. If search is unsuccessful, call the police to report the resident missing, and notify the family/responsible party, attending physician, and corporate staff. Record review of facility's Abuse Prevention Program indicated The residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This report included recognizing signs and symptoms of abuse/neglect, and the definition of neglect as the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. This report included sign of actual physical neglect as Inadequate provision of care; Caregiver indifference to resident's personal care and needs, and leaving someone unattended who needs supervision. The surveyor determined the facility was in non-compliance from 02/14/22 to 02/17/22. The facility took action to monitor Resident #1 upon returning to the facility, staff were in-serviced on elopement procedures, the wander guard was applied to Resident 1's wrist, and the Elopement report was updated.

Based on observation, interview and record review the facility failed to ensure residents were free from neglect for 1 of 5 residents (Resident #1) reviewed for neglect. The facility failed to ensure systems and processes for safe vehicle transfers and supervision were followed by: After being transferred back to the facility from the [MEDICAL TREATMENT] center, Resident #1 was left unattended in the transportation van for almost 2 hours. The van driver forgot he left resident #1 in the van after he transferred another resident off the van into the facility. The van was closed, not running and no A/C was running. The van driver left for lunch and the resident was later discovered in the van almost 2 hours later. This resulted in the resident having a body temperature of 100.5, lethargic, lowered oxygen saturation of 55% and nausea and vomiting. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 6/23/18. While the IJ was removed on 6/24/18, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers This failure placed 5 other residents who are transported to and from [MEDICAL TREATMENT] by the facility van at risk for harm or death if left unattended in a vehicle during periods of hot weather. Findings include: 1. Record review of Resident #1 face sheet documented date of birth 9/11/1953, original admitted [DATE]original admitted [DATE]. Diagnoses: [REDACTED]. MDS (Minimum data set) dated 03/26/18 quarterly review reflected section C. Brief interview for mental status summary score 15 (indicating cognitively intact). Section G transfer: extensive assistance / one person physical assist. Local motion on unit; activity occurs only once or twice / one person physical assist. G 0300 balance during transfer and walking. In the surface to surface transfer 2. Not steady, only able to stabilize with staff assistance. G 0600 mobility device: wheelchair. Plan of care reflected Resident #1 Focus: requires assistance for ADL (activities of daily living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer locomotion, toiletry related to weakness [MEDICAL TREATMENT] and being legally blind. Interventions: assist with ADL care as needed. Focus: Resident #1 is at risk for dehydration as evidenced by [MEDICAL TREATMENT]. Interventions: monitor for signs and symptoms of dehydration 9 including temp. Decreased output, mental status change, dry mucous membrane, orthostatic [MEDICAL CONDITIONS] Monitor lab work as ordered and report as indicated, offer/encourage fluids of choice, monitor for changes in nutritional/hydration status. Focus: Resident #1 has visual impairment related to vision highly impaired legally blind [MEDICAL CONDITION]. Intervention requires verbal instruction when giving instructions/explanation guide her to place on things. 2. In an interview on 06/22/18 at 11:00 a.m. with the facility social worker # 1 revealed the facility van driver had left a resident in the van unattended for almost two hours after picking the resident up and bring her back from [MEDICAL TREATMENT]. Facility social worker #1 revealed Resident # 1's roommate notified the facility that her roommate, Resident #1, had not returned from [MEDICAL TREATMENT] at the usual time. The facility began to look for Resident # 1. Resident #1 was brought into the facility at 1:15 p.m. by the facility van driver left after he returned from his lunch. The social worker #1 revealed the resident was brought back in the van between 11:15 a.m. and 11:30 a.m. The social worker revealed L.V.N. #1 took care of Resident # 1 following the incident. Further interview on 06/22/18 at 4:45 p.m. verified by written statement, with the facility social worker #1 reflected, On 6/22/18, I arrived at work at 6:30 AM. I was making rounds. I stopped by the station to nurse station. I asked how things were going so far. L.V.N #2 station twos nurse. And were sitting at the desk and proceeded to tell me that Resident #1 was left on the bus last night. I asked him what happened L.V.N # 2 said the [MEDICAL TREATMENT] center had called notifying facility that residence was ready to be picked up. The phone call came in around 11 AM. At 1 PM Resident #6, Resident #1 roommate began to ask about her (Resident #1) and where she was in. Around the same time the therapist came by to work with Resident #1 and she was not in her room. The nurse L.V.N. #2, L.V.N. # 4, along with L.V.N #1 said they became worried and looked on both the halls for Resident #1. L.V.N. #2 contacted the transport van driver and ask where Resident #1 was. The transferred van driver told L.V.N. # 2 on the phone that he had already brought her Resident #1 back to the facility. L.V.N. # 2 reported to me that herself (L.V.N. # 2) ,L.V.N. # 4 and L.V.N. #1 began looking for Resident #1. L.V.N. #2 told me that they checked the ERU, then checked Resident #1 room again and checked down the other hall. At that time, all three nurses noticed the transport van driver pushing Resident #1 into the hallway. L.V.N. #2 said the wheelchair was hot to the touch, the Resident #1 was lethargic sweating and appeared not well. L.V.N. #2 told me that Resident #1 sat rate were 55% and temperature was 100.5. 3. In an interview on 06/22/18 at 11:00 a.m. with the facility ADON said At 12:15 p.m. the facility DON and myself with the administrative nurses, we left for lunch. The DON kept getting called from the facility and did not answer the calls. The phone rang again I guess an unknown number, the facility DON answer and the facility nurse told her the van driver left Resident #1 in the van by herself and he admitted he left Resident #1 in the van, he brought Resident #2 in the facility. The ADON revealed they asked the facility DON if they needed to go assess. The Facility DON said no The facility DON stated there has to be a reason. The ADON revealed she called Resident #1 nurse practitioner for attending physician to report the incident and Resident #1 condition with emesis. The ADON revealed she was instructed to watch what she said. 4. In an interview on 06/22/18 at 12:32 p.m. with Resident #1 revealed she did not remember staying in the van for an extended period time. Resident #1 revealed Resident #2 always goes to [MEDICAL TREATMENT] and returns from [MEDICAL TREATMENT] to the facility with her. 5. In an interview on 06/22/18 at 1:22 p.m. with L.V.N. # 2 revealed, Resident #6 called our attention to the fact her roommate Resident #1 had not returned back from [MEDICAL TREATMENT] at the usual time. The staffing coordinator revealed Resident #1 wheelchair when returned was extremely warm, Resident #1 was slow to respond blood pressure 116/60 O2 sats (oxygen saturation) of 55%. 6. In an interview on 06/22/18 at 3:15 p.m. verified by written statement, L.V.N. #1 revealed , On 6/21/18 around 1250 - 1255pm it was brought to my attention by Resident #6 that her roommate Resident #1 had not returned from [MEDICAL TREATMENT]. I (L.V.N.#1) then went to the nursing station and ask L.V.N. #2 who was a second nurse on station two if she had seen Resident #1. The nurse L.V.N. # 2 stated that she had not seen her and that the [MEDICAL TREATMENT] center had called the facility looking for the driver to pick up the residents. I (L.V.N. #1) then went over to station three to ask the nurses the Resident that rides to [MEDICAL TREATMENT] with Resident #1 had returned. The nurse stated that the other resident (Resident #2) had returned. The nurse stated that the other resident had been back at the facility from [MEDICAL TREATMENT] since 11: 15 a.m. LVN #1 went back to the station and L.V.N. #2 informed me L.V.N. #1 that she had spoken with the transport van driver and he had already dropped both residents off at the facility. L.V.N. # 2 and myself then went to the ERU (express recovery unit) area to see if the resident was there. We saw Resident #1, was just being unloaded from the transport van by the transport van driver. Resident #1 was brought into the facility at 1:50 p.m. and she appeared very fatigued and lethargic. I ( L.V.N. #1) followed the resident as the transport van driver was taking her to her room and began assessing her. The Resident #1 was extremely warm to touch and she had a body temp. of 100.2. The metal on the Resident #1 wheelchair was also extremely warm to the touch. Resident #1 was difficult to arouse and 02 sats on assessment was 55% or RA (room air) 3.5 L 02 N/C (nasal cannula) was applied. Resident #1 BP and FSBS were both WNL (within normal limits). L.V.N. # 2 and I (L.V.N. #1) assessed the resident (Resident #1) in removing her jacket and efforts to cool her off. Resident (Resident #1) body temperature was reassessed and noted at 98.6 within 7 to 8 minutes. O2 sats raised to 91% still on 3.5 L 02 I left the resident (Resident #1) room and went back to station #2 to clarify with the nurse what time the second resident (Resident #2) had returned to the facility and she again stated 11:15 a.m. I then asked if I could speak with her resident (Resident #2) to ask a question and permission was given. I (L.V.N. #1) asked Resident #2 if her and Resident #1 came back from [MEDICAL TREATMENT] together and she stated yes. I (L.V.N. #1) also asked her if she was taken off the van before Resident #1 and she (Resident #2) again stated yes. I left (Resident #2) room and returned to Resident #1 room and the 0T (occupational therapist) was in the room. I then proceeded to ask Resident #1 exact same question I asked Resident #2 she stated that she had ridden back from [MEDICAL TREATMENT] with Resident #2. And yes Resident #2. Was taken off the van before she (Resident #1 was. I furthermore ask Resident # 1 if there was an extra amount of time before she was removed from the van after Resident # 2 had been taken off and she (Resident #1) answered yes. I (L.V.N. #1) asked her if the van was off and if the driver was gone for a long period of time and she (Resident #1) again answered yes. I then left the residence room and returned to the nurse station I (L.V.N.#1) contact the facility DON with no answer. The van driver called the facility and asked how Resident #1 was doing and was told she was fine and L.V.N. # 2 asked why did he ask. The transport van driver replied with a sound of relief and replied no reason and disconnected the call. A nursing note was placed on the residence condition. 7. During the interview on 06/22/18 at 1450 (2:50 p.m.) a verified by written statement Occupational Therapist reflected, I first noticed Resident #1 was not back from [MEDICAL TREATMENT] around 11:30 a.m. so I asked the C.N.A. (certified nursing assistant) and Resident #1 roommate did not know why she was not back yet. I later saw the van driver pull up outside the ERU and the driver transferred Resident #1 to her wheelchair and brought her in the building. Both station 2 nurses, C.N.A. and I were in Resident #1 room when her nurse came to assist. Resident #1 was having trouble holding her head up. The nurse took her sats and they were 55%. He (L.V.N.#1) put her on 02 concentrator and she recovered to 78% then 88% then 92% with and in a couple of minutes. I helped Resident #1 take off her sweater and she was very warm and sweaty. The C.N.A. brought Resident #1 Tray and I fed her a few bites and she drank a cup of apple juice plus a cup of water. She (Resident #1) vomited a small amount. The nurse was notified and came to give her [MEDICATION NAME]. 8. During the interview on 06/22/18 at 1340 (1:40 p.m.) verified by written statement L.V.N. # 3 reflected, I was out to lunch with the ADON, DON and treatment nurse at 12 noon, during the lunch about 1313 (1:33 p.m.) the DON started getting a phone call she (DON) did not answer the first few then answered and during the conversation the DON stated she was left van locked she (DON) stated okay and jumped out her seat to go outside and called transport van driver is what she said. I (L.V.N.# 3) remember before leaving the facility at 11:15 am Resident #2 was being brought into the building because she spoke to us. The nurses said resident #1 had a temp of 100.5 hard to arouse and she (Resident #1) was being assisted out of her sweater and vomited 9. During interview on 06/22/18 at 3:55 p.m. with the facility Transport van driver verified with written statement, I brought Resident #2 back to hallway 3, I dropped her off. I totally forgot about Resident #1, I thought I dropped her off also. Transport van driver revealed he went back to the van sat in the van and did his paperwork, with the van running then parked the van turned it off went to the restroom and left for lunch. Transport van driver revealed he left for lunch at 12:10 p.m. and returned at 1:10 p.m. the transport van driver said the facility called me and I told them I had taken her (Resident #1) in the building, but when I returned from lunch I went to the van when I opened the door I heard her (Resident #1) cough and then I knew she was in the van. Transport van driver revealed he took her off the van and took her into the facility. Transport van driver revealed she was in the van for 45 minutes to one hour. Transport van driver revealed he watched the video and worked with the maintenance man for training. Transport van driver revealed Tuesdays and Thursday he usually completes 16 to 18 transports and on Monday, Wednesday, and Friday he does approximately 8 to 12 transports per day. Transport van driver revealed it takes approximately 15 minutes to go from the [MEDICAL TREATMENT] center to the facility. Transport van driver revealed he has a resident he takes to the [MEDICAL TREATMENT] center at 11 o'clock from the facility and picks up Resident # 1 and Resident #2 and transports them back to the facility. 10. In an interview on 06/23/18 at 8:55 a.m. with the facility DON revealed she was at lunch when she was notified and she returned to the facility about 2:30 p.m. to 3:00 p.m. The facility DON asked how she (Resident #1) was doing. The facility DON revealed Resident #1 ate and was participating in therapy. When asked about a Resident signing in and out system so the charge nurse knows where the resident are. The facility DON revealed no they do not have it written, but thought of that after the incident. The facility DON when asked what she expected the trans-work van driver to walk through the van to check for residents. The facility DON stated the administrator and I talked about it and it was not on his check list but we will add it. The facility DON revealed the transportation van drivers' training was he watching training films like secure lock for securing wheelchairs. The facility DON revealed the transportation van driver had worked with maintenance regarding the vehicle maintenance and DPS (Department of Public Safety) film. The facility DON revealed the most residents transported on Tuesday and Thursdays are approximately 6 to 7 residents. Further interview with the DON on 06/23/18 at 12:00 p.m. with Facility DON when asked what should the transport van driver do with residents when he arrives at the facility, the DON said to unhook release the resident with the lift and transfer to the unit. Then notify the home/nurse on the unit go back to the van get another resident when the last resident before parking paperwork check. The DON said I assumed they would have a post check, but I do not know what his paperwork is. The DON revealed it should have had a different outcome. The facility DON revealed he (van driver) should have verified the residence were out of the van. 11. In an interview on 06/23/18 at 10:05 a.m. with maintenance director revealed he only knows of a general job description. The maintenance director revealed he is over the maintenance regarding the van. The maintenance director revealed the transport van driver leaves the van running when he leaves the van. The maintenance director revealed regarding training the facility gives the transport van driver a packet of papers and he and I went through the packet. The maintenance director revealed he could not remember in the training packet that checking for residents after a trip was included and he did not remember the training being focused on residents' care related. The maintenance director revealed he has seen residents that had been transported sitting in the common area by the door they go in and out of the van and he knew they had not been taken back to the ERU nurse station. Further interview on 06/23/18 at 2:15 p.m. with facility maintenance director observation of the facility transport van. Maintenance director revealed the facility van is parked in the designated parking space today at this time that the facility transport van driver would have parked the van at noon prior to his lunch on 06/21/18. 12. The recorded Lubbock weather temperature on 06/21/18 at 12:00 p.m. to 6:00 p.m. temp 97 degree. The recorded Lubbock weather temperature on 06/23/18 at 12:00 p.m. to 6:00 p.m. temp 99 degree. On 06/23/18 at 2:15 p.m. the temperature inside the van with in five minutes registered at 110.7° Fahrenheit. Reference: Lubbock International Tx. Weather. https:www.timeanddate.com/weather/usa/Lubbock/historic. 13. In an interview on 06/23/18 at 11:25 a.m. with alert and interviewable Resident #2 (resident #1's roomate), revealed she returned from [MEDICAL TREATMENT] with Resident #1 about 11:30 a.m. Resident #1 revealed the van driver just brought her right inside the building, she had to make her way back to her room he (van driver) just pushed her in the door and he went back out the door. Resident #2 revealed the van was not running, he (van driver) had to pick someone up. 14. In an interview on 06/23/18 at 12:45 p.m. with Resident # 6 revealed on the day of the incident she was very concerned about 12 to 1 pm when Resident #1 had not returned from [MEDICAL TREATMENT]. Resident #6 revealed she asked the therapist and nurse if they had seen Resident #1. They said we are all looking for her. Resident #6 revealed Resident #1 is usually back in her room by 11:30 a.m. Resident #6 revealed she asked them if they had talked to the van driver or Resident #2 that was in the van with Resident #1. Resident #6 revealed she went to therapy that day and she saw Resident #1 and the van driver bringing her in the back door. Resident #1 could not remember what time she went to therapy that day. Resident #1 said ask The therapist (PTA #1) what time he picked her up for therapy. 15. In an interview on 06/23/18 at 12:53 p.m. and 12:58 p.m. with PTA #1 and PTA #2 (physical therapy assistant) revealed on 06/21/18 Resident #1 was picked up in her room at 1:00 p.m. and assisted to the therapy department for treatment. 16. Record review of Resident #1 progress notes dated 06/21/2018 at 13:40 (1:40 p.m.) signed by L,V,N. #1 reflected Resident #1 returning from [MEDICAL TREATMENT]. Upon assessment resident appeared extremely fatigued, upon assessment resident's wheelchair was extremely hot and resident has a temp. of 100.5, B/P (blood pressure), BS (blood sugar) were both WNL (with in normal limits), resident 02 (oxygen) sat (oxygen saturation rate of the blood) was at 55% on RA (room air). 02 applied via NC (nasal cannula) at 3.5 L. 02 rechecked and noted 91% will continue to monitor resident. Record review of Resident #1 progress note dated 06/21/2018 at 13: 55 (1:55p.m.) signed by L.V.N. #1reflected, we checked of Resident temp. (temperature) noted at 98.6 after clothing was removed and resident was given time to cool off. DON notified of all events will continue to monitor. Record review of Resident #1 progress note dated 06/21/2018 at 16:10 (4:16 p.m.) signed by ADON documented called and notified Resident #1, Son, and FNP (facility nurse practitioner) for attending physician, that there was a delay in returning to her room from the bus after [MEDICAL TREATMENT]. The nurse did a full assessment upon arrival to room. Temperature was 100.5 bp 116/62, 101 (pulse), 20, and O2 sats of 55% on RA (room air) nurse immediately applied 3.5 LPM of oxygen via nasal cannula and reassessed O2 sats were up to 91%. She participated in therapy and is currently sitting in room. I spoke with her and she is present. No s/s (signs and symptoms) of any distress or pain noted. No further concerns from the son was notified and the nurse practitioner give any further orders at this time. Record review of Resident #1 progress notes dated 06/21/2018 at 21:01 (9:01p.m.). signed by L.V.N. #1, On 06/21/2018 at 1315 (3:13 p.m.) Resident #1 return from [MEDICAL TREATMENT] brought in via transportation driver in wheelchair, she was noted as very fatigued and hard to keep aroused. the metal on the residence wheelchair was noted as extremely warm to touch and resident skin was also noted as extremely warm to touch. BP (blood pressure) was noted as WNL (within normal limits) 116/60, 02 sats were at 55%. 02 via N/C (nasal cannula) was immediately applied at 3.5 L, stacks did come up to 91%, lungs were CTA (cleared to auscultation) bilateral RR (resident respirations) at 20. Resident FSBG (finger stick blood sugar) was noted at 120. With an elevated body temperature of 100.5. No noted injury to resident skin, resident denies pain radially pulses were both noted as equal bilaterally. 17. Record review of facility policies and procedures: Abuse Prohibition policy healthcare Center will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of all resident. Effected date 06/01/96, Revised date 03/01/18. Prevention of occurrence Identification of possible incidents or allegations which need investigation Neglect is defined as the failure of the Center, its employees or service providers to provide goods and services to the patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Purpose: to ensure that Center staff are doing all that is within their control to prevent occurrence of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injury of unknown source, and misappropriation of property for all patients. Process: the Center Executive Director, or designee is responsible for operationalizing policies and procedures prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. Facility Job Description Addendum for Positions that Involve Transporting Patients, Residents, Members and or Employees. Effective date 12/1/11. Position summary; in addition to the requirements that are reflected in the employees primary job description, the following document details additional expectations which relate to the safe transportation of patient, residents, members, and or employees to and from the service location during approved activities to pre-determined destination Responsibilities/account abilities: 2.Assist patients, residents, members and/or employees when boarding and disembarking the vehicle. Driver/Vehicle safety Guidelines Effective date 02/01/07 Training checklist for patient transportation vehicle 2. Vehicle is never left unattended with patient/resident inside. 18. Mayo Clinic patient care and health information disease / condition overview: Mayo Clinic: overview heating exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse, a result of body overheating. It's one of the three health risk syndromes, with heat cramps being the mildest and heart [MEDICAL CONDITION] being the most severe. Because of heat exhaustion includes exposure to high temperatures. Symptoms: possible heated job exhaustion signs and symptoms include: Heavy sweating, fatigue, dizziness, witness rapid pulse, low blood pressure upon standing muscle cramps, nausea, headache. Risk factors adults older than 65 are higher risk for heat exhaustion. Prevention: never leave anyone in a parked car. It is not safe to leave a person in a parked car in warm or hot weather. https://www.mayoclinic.org./disease-condition/heat-exhaustion/symptoms-causes /syc- 250 Mayo Clinic hypoxemia (low blood oxygen) - Mayo Clinic Definition [MEDICAL CONDITION] is a new below normal level of oxygen in your blood [MEDICAL CONDITION] is assigned of a problem related to breathing or circulation and may result in various symptoms, such as shortness of breath. Normal [MEDICAL CONDITION] oxygen is approximately 75 to 100 mmHg. Values under 60 mm Hg usually indicate the need for supplemental oxygen. 1998 - (YEAR) foundation for medical education and research (MFMER) https://www.Mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 19. On 06/23/18 at 3:43 p.m., the DON was informed an Immediate Jeopardy. 20. On 06/24/18 at 2:00 p.m. the plan of removal was accepted as follows: This Plan of Removal is in response to the identification of Immediate Jeopardy communicated by the survey team on (MONTH) 23, (YEAR). The Immediate Jeopardy finding was identified in the following area(s): Communication of resident location with non-emergent transportation services - for example family, internal transportation, or external transport to offsite appointments or outings. The Facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiency. Health & Resident Safety Corrective Action On 6/23/2018 a new procedure was initiated for the facility driver, family, or outside vendor transportation service to enhance resident tracking. The transporter will sign the resident out of the facility when going to scheduled appointments, treatments or outings; as well, the nurse will sign them back in via the same form. See attached Exhibit A- Transportation Tracking Log. The Vehicle Safety Policy was amended adding the following: Upon completion of transportation and return of resident to the facility charge nurse, the driver will perform a visual post trip inspection and sign off on the Post Vehicle Inspection Log (Exhibit B) to ensure all residents have been safely removed from the van and the van is ready for the next trip. See attached Exhibit C. Identification Residents which leave the facility for non-emergent reasons have the potential to be affected. Systematic Measures On 6/23/2018, all staff present were educated by NPE, RN staff educator, Center Nurse Executive/DON or designee regarding the new procedure that was initiated for the facility driver, family, or outside vendor transportation service to enhance resident tracking. Education will include how the transporter will sign the resident out of the facility when going to scheduled appointments, treatments or outings; as well, the nurse will sign them back in via the same form. See attached Exhibit A- Transportation Tracking Log All staff will receive training prior to returning to work. All new employees will be educated as part of orientation process. On 6/25/2018 third party contracted vendors which provide medical transfers will be educated prior to transporting facility residents. A letter will be sent to all family members on 6-25-18 and the new process will be reviewed in a special session of the Resident Council on 6-25-18. Quality Assurance and Monitoring The Transportation Tracking Log (Exhibit A) will be monitored daily (M-F) for one month to ensure completion is accurate. Monitoring will continue 2 X weekly for 2 additional months. CED (corporate executive director) and CNE (corporate nurse executive) will report findings of audits in the monthly Performance Improvement (QA&A) meeting monthly for three months or longer until substantial compliance is determined by the Committee. The Performance Improvement Committee consists of but is not limited to the CED, CNE, Assistant Director of Nursing and the Medical Director. 21. On 06/24/18 facility in-service documents and 20 staff interviews related to the plan of removal. The 20 staff interviewed were able to verbalize back in- service information related to the plan of removal. 22. During interviews on 06/24/18 from 10:05 a.m. to 12:35 p.m. with facility staff consisting of 20 staff they revealed they had been trained on abuse and neglect, and the new transportation system. All twenty staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: RNs -2 L.V.N.s - 10 C.N.A - 5 Maintenance director #1 Bookkeeping- 2 The Immediate Jeopardy was removed on 6/24/18, at 2:30 p.m. the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers. A list provided provided by the facility on 6/23/18 revealed 5 other residents transportred by the facility van, Residents' #1, #2, #3, # 4, and #5.

Based on observation, interview and record review the facility failed to ensure residents environment remains as free of accidents and hazard as possible and each resident receives adequate supervision assistance to prevent accidents for one Resident # 1 of 5 residents (Resident#1) reviewed for adequate supervision accident and hazards. After being transferred back to the facility from the [MEDICAL TREATMENT] center, Resident #1 was left unattended in the transportation van for almost 2 hours. The van driver forgot he left resident #1 in the van after he transferred another resident off the van into the facility. The van was closed, not running and no A/C was running. The van driver left for lunch and the resident was later discovered in the van almost 2 hours later. This resulted in the resident having a body temperature of 100.5, lethargic, lowered oxygen saturation of 55% and nausea and vomiting. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 6/23/18. While the IJ was removed on 6/24/18, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers This failure placed 5 other residents who are transported to and from [MEDICAL TREATMENT] by the facility van at risk for harm or death if left unattended in a vehicle during periods of hot weather. Findings include: 1. Record review of Resident #1 face sheet documented date of birth 9/11/1953, original admitted [DATE]original admitted [DATE]. Diagnoses: [REDACTED]. MDS (Minimum data set) dated 03/26/18 quarterly review reflected section C. Brief interview for mental status summary score 15 (indicating cognitively intact). Section G transfer: extensive assistance / one person physical assist. Locomotion on unit; activity occurs only once or twice / one person physical assist. G 0300 balance during transfer and walking. In the surface to surface transfer 2. Not steady, only able to stabilize with staff assistance. G 0600 mobility device: wheelchair. Plan of care reflected Resident #1 Focus: requires assistance for ADL (activities of daily living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer locomotion, toiletry related to weakness [MEDICAL TREATMENT] and being legally blind. Interventions: assist with ADL care as needed. Focus: Resident #1 is at risk for dehydration as evidenced by [MEDICAL TREATMENT]. Interventions: monitor for signs and symptoms of dehydration including temp. Decreased output, mental status change, dry mucous membrane, orthostatic [MEDICAL CONDITIONS] Monitor lab work as ordered and report as indicated, offer/encourage fluids of choice, monitor for changes in nutritional/hydration status. Focus: Resident #1 has visual impairment related to vision highly impaired legally blind [MEDICAL CONDITION]. Intervention requires verbal instruction when giving instructions/explanation guide her to place on things. 2. In an interview on 06/22/18 at 11:00 a.m. with the facility social worker # 1 revealed the facility van driver had left a resident in the van unattended for almost two hours after picking the resident up and bring her back from [MEDICAL TREATMENT]. Facility social worker #1 revealed Resident # 1's roommate (Resident #2) notified the facility that her roommate,(Resident #1), had not returned from [MEDICAL TREATMENT] at the usual time. The facility began to look for Resident # 1. Resident #1 was brought into the facility at 1:15 p.m. by the facility van driver after his returned from his hour lunch break.The social worker #1 revealed the resident was brought back in the van to the facility between 11:15 a.m. and 11:30 a.m. The social worker revealed L.V.N. #1 took care of Resident # 1 following the incident. Further interview on 06/22/18 at 4:45 p.m. verified by written statement, with the facility social worker #1 reflected, On 6/22/18, I arrived at work at 6:30 AM. I was making rounds. I stopped by the station to nurse station. I asked how things were going so far. L.V.N #2 station twos nurse. And were sitting at the desk and proceeded to tell me that Resident #1 was left on the bus last night. I asked him what happened L.V.N # 2 said the [MEDICAL TREATMENT] center had called notifying facility that residence was ready to be picked up. The phone call came in around 11 AM. At 1 PM Resident #6, Resident #1 roommate began to ask about her (Resident #1) and where she was in. Around the same time the therapist came by to work with Resident #1 and she was not in her room. The nurse L.V.N. #2, L.V.N. # 4, along with L.V.N #1 said they became worried and looked both the halls for Resident #1. L.V.N. #2 contacted the transport van driver and ask where Resident #1 was. The transferred van driver told L.V.N. # 2 on the phone that he had already brought her Resident #1 back to the facility. L.V.N. # 2 reported to me that herself (L.V.N. # 2) ,L.V.N. # 4 and L.V.N. #1 began looking for Resident #1. L.V.N. #2 told me that they checked the ERU, then checked Resident #1 room again and checked down the other hall. At that time, all three nurses noticed the transport van driver pushing Resident #1 into the hallway. L.V.N. #2 said the wheelchair was hot to the touch, the Resident #1 was lethargic sweating and appeared not well. L.V.N. #2 told me that Resident #1 sat rate were 55% and temperature was 100.5. 3. In an interview on 06/22/18 at 11:00 a.m. with the facility ADON revealed she called Resident #1 nurse practitioner for attending physician to report the incident and Resident #1 condition with emesis. 4. An interview on 06/22/18 at 12:32 p.m. with Resident #1 revealed she did not remember staying in the van for an extended period time. Resident #1 revealed Resident #2 always goes to [MEDICAL TREATMENT] and returns from [MEDICAL TREATMENT] to the facility with her. 5. In an interview on 06/22/18 at 1:22 p.m. with L.V.N. # 2 revealed, Resident #6 called our attention to the fact her roommate Resident #1 had not returned back from [MEDICAL TREATMENT] at the usual time. The staffing coordinator revealed Resident #1 wheelchair when returned was extremely warm, Resident #1 was slow to respond blood pressure 116/60 O2 sats (oxygen saturation) of 55%. 6. In an interview on 06/22/18 at 3:15 p.m. verified by written statement, L.V.N. #1 revealed , On 6/21/18 around 1250 - 1255 pm it was brought to my attention by Resident #6 that her roommate Resident #1 had not returned from [MEDICAL TREATMENT]. I (L.V.N.#1) then went to the nursing station and ask L.V.N. # #2 who was a second nurse on station two if she had seen Resident #1. The nurse L.V.N. # 2 stated that she had not seen her and that the [MEDICAL TREATMENT] center had called the facility looking for the driver to pick up the residents. I (L.V.N. #1) then went over to station three to ask the nurses the Resident that rides to [MEDICAL TREATMENT] with Resident #1 had returned. The nurse stated that the other resident (Resident #2) had returned. The nurse stated that the other resident had been back at the facility from [MEDICAL TREATMENT] since 11: 15 a.m. LVN #1 went back to the station and L.V.N. #2 informed me L.V.N. #1 that she had spoken with the transport van driver and he had already dropped both residents off at the facility. L.V.N. # 2 and myself then went to the ERU (express recovery unit) area to see if the resident was there. We saw Resident #1, was just being unloaded from the transport van by the transport van driver. Resident #1 was brought into the facility at 1:50 p.m. and she appeared very fatigued and lethargic. I ( L.V.N. #1) followed the resident as the transport van driver was taking her to her room and began assessing her. The Resident #1 was extremely warm to touch and she had a body temp. of 100.2. The metal on the Resident #1 wheelchair was also extremely warm to the touch. Resident #1 was difficult to arouse and 02 sats on assessment was 55% or RA (room air) 3.5 L 02 N/C (nasal cannula) was applied. Resident #1 BP and FSBS were both WNL (within normal limits). L.V.N. # 2 and I (L.V.N. #1) assessed the resident (Resident #1) in removing her jacket and efforts to cool her off. Resident (Resident #1) body temperature was reassessed and noted at 98.6 within 7 to 8 minutes. O2 sats raised to 91% still on 3.5 L 02 I left the resident (Resident #1) room and went back to station #2 to clarify with the nurse what time the second resident (Resident #2) had returned to the facility and she again stated 11:15 a.m. I then asked if I could speak with her resident (Resident #2) to ask a question and permission was given. I (L.V.N. #1) asked Resident #2 if her and Resident #1 came back from [MEDICAL TREATMENT] together and she stated yes. I (L.V.N. #1) also asked her if she was taken off the van before Resident #1 and she (Resident #2) again stated yes. I left (Resident #2) room and returned to Resident #1 room and the 0T (occupational therapist) was in the room. I ( L.V.N.#1) then proceeded to ask Resident #1 exact same question I asked Resident #2 she stated that she had ridden back from [MEDICAL TREATMENT] with Resident #2,and yes Resident #2 was taken off the van before she (Resident #1 was. I furthermore ask Resident # 1 if there was an extra amount of time before she was removed from the van after Resident # 2 had been taken off and she (Resident #1) answered yes. I (L.V.N. #1) asked her if the van was off and if the driver was gone for a long period of time and she (Resident #1) again answered yes. I then left the residence room and returned to the nurse station I (L.V.N.#1) contact the facility DON with no answer. The van driver called the facility and asked how Resident #1 was doing and was told she was fine and L.V.N. # 2 asked why did he ask. The transport van driver replied with a sound of relief and replied no reason and disconnected the call. 7. During the interview on 06/22/18 at 1450 (2:50 p.m.) a verified by written statement Occupational Therapist reflected, I first noticed Resident #1 was not back from [MEDICAL TREATMENT] around 11:30 a.m. so I asked the C.N.A. (certified nursing assistant) and Resident #1 roommate did not know why she was not back yet. I later saw the van driver pull up outside the ERU and the driver transferred Resident #1 to her wheelchair and brought her in the building. Both station 2 nurses, C.N.A. and I were in Resident #1 room when her nurse came to assist. Resident #1 was having trouble holding her head up. The nurse took her sats and they were 55%. He (L.V.N.#1) put her on 02 concentrator and she recovered to 78% then 88% then 92% with and in a couple of minutes. I helped Resident #1 take off her sweater and she was very warm and sweaty. The C.N.A. brought Resident #1 tray and I (OT) fed her a few bits by and she drank a cup of apple juice plus a cup of water. She (Resident #1) vomited a small amount. The nurse was notified and came to give her [MEDICATION NAME]. 8. During the interview on 06/22/18 at 1340 (1:40 p.m.) verified by written statement L.V.N. # 3 reflected, I was out to lunch with the ADON, DON and treatment nurse at 12 noon, during the lunch about 1313 (1:33 p.m.) the DON started getting a phone call she (DON) did not answer the first few then answered and during the conversation the DON stated she was left van locked she (DON) stated okay and jumped out her seat to go outside and called transport van driver is what she said. I (L.V.N.# 3) remember before leaving the facility at 11:15 am Resident #2 was being brought into the building because she spoke to us. The nurses said resident #1 had a temp of 100.5 hard to arouse and she (Resident #1) was being assisted out of her sweater and vomited. 9. During interview on 06/22/18 at 3:55 p.m. with the facility Transport van driver verified by a written statement, I brought Resident #2 back to station (hall) 3, I dropped her off. I totally forgot about Resident #1, I thought I dropped her off also. Transport van driver revealed he went back to the van sat in the van and did his paperwork, with the van running then parked the van turned it off went to the restroom and left for lunch. Transport van driver revealed he left for lunch at 12:10 p.m. and returned at 1:10 p.m. the transport van driver said the facility called me and I told them I had taken her (Resident #1) in the building, but when I returned from lunch I went to the van when I opened the door I heard her (Resident #1) cough and then I knew she was in the van. Transport van driver revealed he took her off the van and took her into the facility. Transport van driver revealed she was in the van for 45 minutes to one hour. Transport van driver revealed he watched the video and worked with the maintenance man for training. Transport van driver revealed Tuesdays and Thursday he usually completes 16 to 18 transports and on Monday, Wednesday, and Friday he does approximately 8 to 12 transports per day. Transport van driver revealed it takes approximately 15 minutes to go from the [MEDICAL TREATMENT] center to the facility. Transport van driver revealed he has a resident he takes to the [MEDICAL TREATMENT] center at 11 o'clock from the facility and picks up Resident # 1 and Resident #2 and transports them back to the facility. 10. In an interview on 06/23/18 at 8:55 a.m. with the facility DON revealed she was at lunch when she was notified and she returned to the facility about 2:30 p.m. to 3:00 p.m. The facility DON asked how she (Resident #1) was doing. The facility DON revealed Resident #1 ate and was participating in therapy. When asked about the Residents signing in and out system, so the charge nurse would know the location of the residents. The facility DON revealed no they do not have it written, but thought of that after the incident. The facility DON when asked what she expected the trans-work van driver to walk through the van to check for residents. The facility DON stated the administrator and I talked about it and it was not on his check list but we will add it. The facility DON revealed the transportation van drivers' training was he watching training films like secure lock for securing wheelchairs. The facility DON revealed the transportation van driver had worked with maintenance regarding the vehicle maintenance and DPS (Department of Public Safety) film. The facility DON revealed the most residents transported on Tuesday and Thursdays are approximately 6 to 7 residents. Further interview with the DON on 06/23/18 at 12:00 p.m. with Facility DON when asked what should the transport van driver do with residents when he arrives at the facility, the DON said to unhook release the resident with the lift and transfer to the unit. Then notify the home/nurse on the unit go back to the van get another resident when the last resident before parking paperwork check. The DON said I assumed they would have a post check, but I do not know what his paperwork is. The DON revealed it should have had a different outcome. The facility DON revealed he (van driver) should have verified the residence were out of the van. 11. In an interview on 06/23/18 at 10:05 a.m. with maintenance director revealed he only knows of a general job description. The maintenance director revealed he is over the maintenance regarding the van. The maintenance director revealed the transport van driver leaves the van running when he leaves the van. The maintenance director revealed regarding training the facility gives the transport van driver a packet of papers and he and I went through the packet. The maintenance director revealed he could not remember in the training packet that checking for residents after a trip was included and he did not remember the training being focused on residents' care related. The maintenance director revealed he has seen residents that had been transported sitting in the common area by the door they go in and out of the van and he knew they had not been taken back to the ERU nurse station. Further interview on 06/23/18 at 2:15 p.m. with facility maintenance director observation of the facility transport van. Maintenance director revealed the facility van is parked in the designated parking space today at this time that the facility transport van driver would have parked the van at noon prior to his lunch on 06/21/18. 12. The recorded Lubbock weather temperature on 06/21/18 at 12:00 p.m. to 6:00 p.m. temp 97 degree. The recorded Lubbock weather temperature on 06/23/18 at 12:00 p.m. to 6:00 p.m. temp 99 degree. On 06/23/18 at 2:15 the temperature inside the van with in five minutes registered at 110.7° Fahrenheit. Reference: Lubbock International Tx. Weather. https:www.timeanddate.com/weather/usa/Lubbock/historic. 13. In an interview on 06/23/18 at 11:25 a.m. with alert and interviewable Resident #2 (resident #1's roomate), revealed she returned from [MEDICAL TREATMENT] with Resident #1 about 11:30 a.m. Resident #1 revealed the van driver just brought her right inside the building, she had to make her way back to her room he (van driver) just pushed her in the door and he went back out the door. Resident #2 revealed the van was not running, he (van driver) had to pick someone up. 14. In an interview on 06/23/18 at 12:45 p.m. with Resident # 6 revealed on the day of the incident she was very concerned about 12 to 1 pm when Resident #1 had not returned from [MEDICAL TREATMENT]. Resident #6 revealed she asked the therapist and nurse if they had seen Resident #1. They said we are all looking for her. Resident #6 revealed Resident #1 is usually back in her room by 11:30 a.m. Resident #6 revealed she asked them if they had talked to the van driver or Resident #2 that was in the van with Resident #1. Resident #6 revealed she went to therapy that day and she saw Resident #1 and the van driver bringing her in the back door. Resident #1 could not remember what time she went to therapy that day. Resident #1 said ask The therapist (PTA #1) what time he picked her up for therapy. 15. In an interview on 06/23/18 at 12:53 p.m. and 12:58 p.m. with PTA #1 and PTA #2 (physical therapy assistant) revealed on 06/21/18 Resident #1 was picked up in her room at 1:00 p.m. and assisted to the therapy department for treatment. 16. Record review of Resident #1 progress notes dated 06/21/2018 at 13:40 (1:40 p.m.) signed by L,V,N. #1 reflected Resident #1 returning from [MEDICAL TREATMENT]. Upon assessment resident appeared extremely fatigued, upon assessment resident's wheelchair was extremely hot and resident has a temp. of 100.5, B/P (blood pressure), BS (blood sugar) were both WNL (with in normal limits), resident 02 (oxygen) sat (oxygen saturation rate of the blood) was at 55% on RA (room air). 02 applied via NC (nasal cannula) at 3.5 L. 02 rechecked and noted 91% will continue to monitor resident. Record review of Resident #1 progress note dated 06/21/2018 at 13: 55 (1:55p.m.) signed by L.V.N. #1reflected, we checked of Resident temp. (temperature) noted at 98.6 after clothing was removed and resident was given time to cool off. DON notified of all events will continue to monitor. Record review of Resident #1 progress note dated 06/21/2018 at 16:10 (4:16 p.m.) signed by ADON documented called and notified Resident #1, Son, and FNP (facility nurse practitioner) for attending physician, that there was a delay in returning to her room from the bus after [MEDICAL TREATMENT]. The nurse did a full assessment upon arrival to room. Temperature was 100.5 bp 116/62, 101 (pulse), 20, and O2 sats of 55% on RA (room air) nurse immediately applied 3.5 LPM of oxygen via nasal cannula and reassessed O2 sats were up to 91%. She participated in therapy and is currently sitting in room. No s/s (signs and symptoms) of any distress or pain noted. No further concerns from the son was notified and the nurse practitioner give any further orders at this time. Record review of Resident #1 progress notes dated 06/21/2018 at 21:01 (9:01p.m.). signed by L.V.N. #1, On 06/21/2018 at 1315 (3:13 p.m.) Resident #1 return from [MEDICAL TREATMENT] brought in via transportation driver in wheelchair, she was noted as very fatigued and hard to keep aroused. the metal on the residence wheelchair was noted as extremely warm to touch and resident skin was also noted as extremely warm to touch. BP (blood pressure) was noted as WNL (within normal limits) 116/60, 02 sats were at 55%. 02 via N/C (nasal cannula) was immediately applied at 3.5 L, stacks did come up to 91%, lungs were CTA (cleared to auscultation) bilateral RR (resident respirations) at 20. Resident FSBG (finger stick blood sugar) was noted at 120. With an elevated body temperature of 100.5. No noted injury to resident skin, resident denies pain, Radial and pedal pulse both noted as equal bilaterally. 17. Record review of facility policies and procedures: Facility Job Description Addendum for Positions that Involve Transporting Patients, Residents, Members and or Employees. Effective date 12/1/11. Position summary; in addition to the requirements that are reflected in the employees primary job description, the following document details additional expectations which relate to the safe transportation of patient, residents, members, and or employees to and from the service location during approved activities to pre-determined destination Responsibilities/account abilities: 2.Assist patients, residents, members and/or employees when boarding and disembarking the vehicle. Driver/Vehicle safety Guidelines Effective date 02/01/07 Training checklist for patient transportation vehicle 2. Vehicle is never left unattended with patient/resident inside. 18. Mayo Clinic patient care and health information disease / condition overview: Mayo Clinic: overview heating exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse, a result of body overheating. It's one of the three health risk syndromes, with heat cramps being the mildest and heart [MEDICAL CONDITION] being the most severe. Because of heat exhaustion includes exposure to high temperatures. Symptoms: possible heated job exhaustion signs and symptoms include: Heavy sweating, fatigue, dizziness, witness rapid pulse, low blood pressure upon standing muscle cramps, nausea, headache. Risk factors adults older than 65 are higher risk for heat exhaustion. Prevention: never leave anyone in a parked car. It is not safe to leave a person in a parked car in warm or hot weather. https://www.mayoclinic.org./disease-condition/heat-exhaustion/symptoms-causes /syc- 250 Mayo Clinic hypoxemia (low blood oxygen) - Mayo Clinic Definition [MEDICAL CONDITION] is a new below normal level of oxygen in your blood [MEDICAL CONDITION] is assigned of a problem related to breathing or circulation and may result in various symptoms, such as shortness of breath. Normal [MEDICAL CONDITION] oxygen is approximately 75 to 100 mmHg. Values under 60 mm Hg usually indicate the need for supplemental oxygen. 1998 - (YEAR) foundation for medical education and research (MFMER) https://www.Mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 19. On 06/23/18 at 3:43 p.m., the DON was informed of an Immediate Jeopardy. 20. On 06/24/18 at 2:00 p.m. the plan of removal was accepted as follows: This Plan of Removal is in response to the identification of Immediate Jeopardy communicated by the survey team on (MONTH) 23, (YEAR). The Immediate Jeopardy finding was identified in the following area(s): Communication of resident location with non-emergent transportation services - for example family, internal transportation, or external transport to offsite appointments or outings. The Facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiency. Health & Resident Safety Corrective Action On 6/23/2018 a new procedure was initiated for the facility driver, family, or outside vendor transportation service to enhance resident tracking. The transporter will sign the resident out of the facility when going to scheduled appointments, treatments or outings; as well, the nurse will sign them back in via the same form. See attached Exhibit A- Transportation Tracking Log. The Vehicle Safety Policy was amended adding the following: Upon completion of transportation and return of resident to the facility charge nurse, the driver will perform a visual post trip inspection and sign off on the Post Vehicle Inspection Log (Exhibit B) to ensure all residents have been safely removed from the van and the van is ready for the next trip. See attached Exhibit C. Identification Residents which leave the facility for non-emergent reasons have the potential to be affected. Systematic Measures On 6/23/2018, all staff present were educated by NPE, RN staff educator, Center Nurse Executive/DON or designee regarding the new procedure that was initiated for the facility driver, family, or outside vendor transportation service to enhance resident tracking. Education will include how the transporter will sign the resident out of the facility when going to scheduled appointments, treatments or outings; as well, the nurse will sign them back in via the same form. See attached Exhibit A- Transportation Tracking Log All staff will receive training prior to returning to work. All new employees will be educated as part of orientation process. On 6/25/2018 third party contracted vendors which provide medical transfers will be educated prior to transporting facility residents. A letter will be sent to all family members on 6-25-18 and the new process will be reviewed in a special session of the Resident Council on 6-25-18. Quality Assurance and Monitoring The Transportation Tracking Log (Exhibit A) will be monitored daily (M-F) for one month to ensure completion is accurate. Monitoring will continue 2 X weekly for 2 additional months. CED ( Chief Executive Director) (administrator) and CNE (Chief Nurse Executive) (Director of Nursing) will report findings of audits in the monthly Performance Improvement (QA&A) meeting monthly for three months or longer until substantial compliance is determined by the Committee. The Performance Improvement Committee consists of but is not limited to the CED, CNE, Assistant Director of Nursing and the Medical Director. 21. On 06/24/18 facility in-service documents and 20 staff interviews related to the plan of removal. The 20 staff interviewed were able to verbalize back in- service information related to the plan of removal. 22. During interviews on 06/24/18 from 10:05 a.m. to 12:35 p.m. with facility staff consisting of 20 staff they revealed they had been trained on abuse and neglect, and the new transportation system. All twenty staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: RNs -2 L.V.N.s - 10 C.N.A - 5 Maintenance director #1 Bookkeeping- 2 The Immediate Jeopardy was removed on 6/24/18, at 2:30 p.m. the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers. A list provided provided by the facility on 6/23/18 revealed 5 other residents transportred by the facility van, Residents' #1, #2, #3, # 4, and #5.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 5 residents (Resident #1) reviewed for neglect. The facility failed to ensure systems and processes for safe vehicle transfers and supervision were followed by: After being transferred back to the facility from the [MEDICAL TREATMENT] center, Resident #1 was left unattended in the transportation van for almost 2 hours. The van driver forgot he left resident #1 in the van after he transferred another resident off the van into the facility. The van was closed, not running and no A/C was running. The van driver left for lunch and the resident was later discovered in the van almost 2 hours later. This resulted in the resident having a body temperature of 100.5, lethargic, lowered oxygen saturation of 55% and nausea and vomiting. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 6/23/18. While the IJ was removed on 6/24/18, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers This failure placed 5 other residents who are transported to and from [MEDICAL TREATMENT] by the facility van at risk for harm or death if left unattended in a vehicle during periods of hot weather. Findings include: 1. Record review of facility policies and procedures: Abuse Prohibition policy healthcare Center will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of all resident. Effected date 06/01/96, Revised date 03/01/18. Prevention of occurrence Identification of possible incidents or allegations which need investigation Neglect is defined as the failure of the Center, its employees or service providers to provide goods and services to the patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Purpose: to ensure that Center staff are doing all that is within their control to prevent occurrence of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injury of unknown source, and misappropriation of property for all patients. Process: the Center Executive Director, or designee is responsible for operationalizing policies and procedures prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. Facility Job Description Addendum for Positions that Involve Transporting Patients, Residents, Members and or Employees. Effective date 12/1/11. Position summary; in addition to the requirements that are reflected in the employees primary job description, the following document details additional expectations which relate to the safe transportation of patient, residents, members, and or employees to and from the service location during approved activities to pre-determined destination Responsibilities/account abilities: Assist patients, residents, members and/or employees when boarding and disembarking the vehicle. Driver/Vehicle safety Guidelines Effective date 02/01/07 Training checklist for patient transportation vehicle - Vehicle is never left unattended with patient/resident inside. 2. Record review of Resident #1 face sheet documented date of birth 9/11/1953, original admitted [DATE]readmitted [DATE]. Diagnoses: [REDACTED]. MDS (Minimum data set) dated 03/26/18 quarterly review reflected section C. Brief interview for mental status summary score 15 (indicating cognitively intact). Section G transfer: extensive assistance / one person physical assist. Locomotion on unit; activity occurs only once or twice / one person physical assist. G 0300 balance during transfer and walking. In the surface to surface transfer 2. Not steady, only able to stabilize with staff assistance. G 0600 mobility device: wheelchair. Plan of care reflected Resident #1 Focus: requires assistance for ADL (activities of daily living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer locomotion, toiletry related to weakness [MEDICAL TREATMENT] and being legally blind. Interventions: assist with ADL care as needed. Focus: Resident #1 is at risk for dehydration as evidenced by [MEDICAL TREATMENT]. Interventions: monitor for signs and symptoms of dehydration 9 including temp. Decreased output, mental status change, dry mucous membrane, orthostatic [MEDICAL CONDITIONS] Monitor lab work as ordered and report as indicated, offer/encourage fluids of choice, monitor for changes in nutritional/hydration status. Focus: Resident #1 has visual impairment related to vision highly impaired legally blind [MEDICAL CONDITION]. Intervention requires verbal instruction when giving instructions/explanation guide her to place on things. 3. In an interview on 06/22/18 at 11:00 a.m. with the facility social worker # 1 revealed the facility van driver had left a resident in the van unattended for almost two hours after picking the resident up and bring her back from [MEDICAL TREATMENT]. Facility social worker #1 revealed Resident # 1's roommate notified the facility that her roommate, Resident #1, had not returned from [MEDICAL TREATMENT] at the usual time. The facility began to look for Resident # 1. Resident #1 was brought into the facility at 1:15 p.m. by the facility van driver left after he returned from his lunch. The social worker #1 revealed the resident was brought back in the van between 11:15 a.m. and 11:30 a.m. The social worker revealed L.V.N. #1 took care of Resident # 1 following the incident. Further interview on 06/22/18 at 4:45 p.m. verified by written statement, with the facility social worker #1 reflected, On 6/22/18, I arrived at work at 6:30 AM. I was making rounds. I stopped by the station to nurse station. I asked how things were going so far. L.V.N #2 station twos nurse. And were sitting at the desk and proceeded to tell me that Resident #1 was left on the bus last night. I asked him what happened L.V.N # 2 said the [MEDICAL TREATMENT] center had called notifying facility that residence was ready to be picked up. The phone call came in around 11 AM. At 1 PM Resident #6, Resident #1 roommate began to ask about her (Resident #1) and where she was in. Around the same time the therapist came by to work with Resident #1 and she was not in her room. The nurse L.V.N. #2, L.V.N. # 4, along with L.V.N #1 said they became worried and looked on both the halls for Resident #1. L.V.N. #2 contacted the transport van driver and ask where Resident #1 was. The transferred van driver told L.V.N. # 2 on the phone that he had already brought her Resident #1 back to the facility. L.V.N. # 2 reported to me that herself (L.V.N. # 2) ,L.V.N. # 4 and L.V.N. #1 began looking for Resident #1. L.V.N. #2 told me that they checked the ERU, then checked Resident #1 room again and checked down the other hall. At that time, all three nurses noticed the transport van driver pushing Resident #1 into the hallway. L.V.N. #2 said the wheelchair was hot to the touch, the Resident #1 was lethargic sweating and appeared not well. L.V.N. #2 told me that Resident #1 sat rate were 55% and temperature was 100.5. 4. In an interview on 06/22/18 at 11:00 a.m. with the facility ADON said At 12:15 p.m. the facility DON and myself with the administrative nurses, we left for lunch. The DON kept getting called from the facility and did not answer the calls. The phone rang again I guess an unknown number, the facility DON answer and the facility nurse told her the van driver left Resident #1 in the van by herself and he admitted he left Resident #1 in the van, he brought Resident #2 in the facility. The ADON revealed they asked the facility DON if they needed to go assess. The Facility DON said no The facility DON stated there has to be a reason. The ADON revealed she called Resident #1 nurse practitioner for attending physician to report the incident and Resident #1 condition with emesis. 5. An interview on 06/22/18 at 12:32 p.m. with Resident #1 revealed she did not remember staying in the van for an extended period time. Resident #1 revealed Resident #2 always goes to [MEDICAL TREATMENT] and returns from [MEDICAL TREATMENT] to the facility with her. 6. In an interview on 06/22/18 at 1:22 p.m. with L.V.N. # 2 revealed, Resident #6 called our attention to the fact her roommate Resident #1 had not returned back from [MEDICAL TREATMENT] at the usual time. The staffing coordinator revealed Resident #1 wheelchair when returned was extremely warm, Resident #1 was slow to respond blood pressure 116/60 O2 sats (oxygen saturation) of 55%. 7. In an interview on 06/22/18 at 3:15 p.m. verified by written statement, L.V.N. #1 revealed , On 6/21/18 around 1250 - 1255pm it was brought to my attention by Resident #6 that her roommate Resident #1 had not returned from [MEDICAL TREATMENT]. I (L.V.N.#1) then went to the nursing station and ask L.V.N. #2 who was a second nurse on station two if she had seen Resident #1. The nurse L.V.N. # 2 stated that she had not seen her and that the [MEDICAL TREATMENT] center had called the facility looking for the driver to pick up the residents. I (L.V.N. #1) then went over to station three to ask the nurses the Resident that rides to [MEDICAL TREATMENT] with Resident #1 had returned. The nurse stated that the other resident (Resident #2) had returned. The nurse stated that the other resident had been back at the facility from [MEDICAL TREATMENT] since 11: 15 a.m. LVN #1 went back to the station and L.V.N. #2 informed me L.V.N. #1 that she had spoken with the transport van driver and he had already dropped both residents off at the facility. L.V.N. # 2 and myself then went to the ERU (express recovery unit) area to see if the resident was there. We saw Resident #1, was just being unloaded from the transport van by the transport van driver. Resident #1 was brought into the facility at 1:50 p.m. and she appeared very fatigued and lethargic. I ( L.V.N. #1) followed the resident as the transport van driver was taking her to her room and began assessing her. The Resident #1 was extremely warm to touch and she had a body temp. of 100.2. The metal on the Resident #1 wheelchair was also extremely warm to the touch. Resident #1 was difficult to arouse and 02 sats on assessment was 55% or RA (room air) 3.5 L 02 N/C (nasal cannula) was applied. Resident #1 BP and FSBS were both WNL (within normal limits). L.V.N. # 2 and I (L.V.N. #1) assessed the resident (Resident #1) in removing her jacket and efforts to cool her off. Resident (Resident #1) body temperature was reassessed and noted at 98.6 within 7 to 8 minutes. O2 sats raised to 91% still on 3.5 L 02 I left the resident (Resident #1) room and went back to station #2 to clarify with the nurse what time the second resident (Resident #2) had returned to the facility and she again stated 11:15 a.m. I then asked if I could speak with her resident (Resident #2) to ask a question and permission was given. I (L.V.N. #1) asked Resident #2 if her and Resident #1 came back from [MEDICAL TREATMENT] together and she stated yes. I (L.V.N. #1) also asked her if she was taken off the van before Resident #1 and she (Resident #2) again stated yes. I left (Resident #2) room and returned to Resident #1 room and the 0T (occupational therapist) was in the room. I (L.V.N. #1) gave her a chance to leave the room and she declined. I then proceeded to ask Resident #1 exact same question I asked Resident #2 she stated that she had ridden back from [MEDICAL TREATMENT] with Resident #2. And yes Resident #2. Was taken off the van before she (Resident #1 was. I furthermore ask Resident # 1 if there was an extra amount of time before she was removed from the van after Resident # 2 had been taken off and she (Resident #1) answered yes. I (L.V.N. #1) asked her if the van was off and if the driver was gone for a long period of time and she (Resident #1) again answered yes. I then left the residence room and returned to the nurse station I (L.V.N.#1) contact the facility DON with no answer. The van driver called the facility and asked how Resident #1 was doing and was told she was fine and L.V.N. # 2 asked why did he ask. The transport van driver replied with a sound of relief and replied no reason and disconnected the call. A nursing note was placed on the residence condition. No further steps were taken due to no return calls from DON 8. During the interview on 06/22/18 at 1450 (2:50 p.m.) a verified by written statement Occupational Therapist reflected, I first noticed Resident #1 was not back from [MEDICAL TREATMENT] around 11:30 a.m. so I asked the C.N.A. (certified nursing assistant) and Resident #1 roommate did not know why she was not back yet. I later saw the van driver pull up outside the ERU and the driver transferred Resident #1 to her wheelchair and brought her in the building. Both station 2 nurses, C.N.A. and I were in Resident #1 room when her nurse came to assist. Resident #1 was having trouble holding her head up. The nurse took her sats and they were 55%. He (L.V.N.#1) put her on 02 concentrator and she recovered to 78% then 88% then 92% with and in a couple of minutes. I helped Resident #1 take off her sweater and she was very warm and sweaty. The C.N.A. brought Resident #1 Tray and I fed her a few bites and she drank a cup of apple juice plus a cup of water. She (Resident #1) vomited a small amount. The nurse was notified and came to give her [MEDICATION NAME]. 9. During the interview on 06/22/18 at 1340 (1:40 p.m.) verified by written statement L.V.N. # 3 reflected, I was out to lunch with the ADON, DON and treatment nurse at 12 noon, during the lunch about 1313 (1:33 p.m.) the DON started getting a phone call she (DON) did not answer the first few then answered and during the conversation the DON stated she was left van locked she (DON) stated okay and jumped out her seat to go outside and called transport van driver is what she said. I (L.V.N.# 3) remember before leaving the facility at 11:15 am Resident #2 was being brought into the building because she spoke to us. The nurses said resident #1 had a temp of 100.5 hard to arouse and she (Resident #1) was being assisted out of her sweater and vomited 10. During interview on 06/22/18 at 3:55 p.m. with the facility Transport van driver verified with written statement, I brought Resident #2 back to hallway 3, I dropped her off. I totally forgot about Resident #1, I thought I dropped her off also. Transport van driver revealed he went back to the van sat in the van and did his paperwork, with the van running then parked the van turned it off went to the restroom and left for lunch. Transport van driver revealed he left for lunch at 12:10 p.m. and returned at 1:10 p.m. the transport van driver said the facility called me and I told them I had taken her (Resident #1) in the building, but when I returned from lunch I went to the van when I opened the door I heard her (Resident #1) cough and then I knew she was in the van. Transport van driver revealed he took her off the van and took her into the facility. Transport van driver revealed she was in the van for 45 minutes to one hour. Transport van driver revealed he watched the video and worked with the maintenance man for training. Transport van driver revealed Tuesdays and Thursday he usually completes 16 to 18 transports and on Monday, Wednesday, and Friday he does approximately 8 to 12 transports per day. Transport van driver revealed it takes approximately 15 minutes to go from the [MEDICAL TREATMENT] center to the facility. Transport van driver revealed he has a resident he takes to the [MEDICAL TREATMENT] center at 11 o'clock from the facility and picks up Resident # 1 and Resident #2 and transports them back to the facility. 11. In an interview on 06/23/18 at 8:55 a.m. with the facility DON revealed she was at lunch when she was notified and she returned to the facility about 2:30 p.m. to 3:00 p.m. The facility DON asked how she (Resident #1) was doing. The facility DON revealed Resident #1 ate and was participating in therapy. When asked about a Resident signing in and out system so the charge nurse knows where the resident are. The facility DON revealed no they do not have it written, but thought of that after the incident. The facility DON when asked what she expected the trans-work van driver to walk through the van to check for residents. The facility DON stated the administrator and I talked about it and it was not on his check list but we will add it. The facility DON revealed the transportation van drivers' training was he watching training films like secure lock for securing wheelchairs. The facility DON revealed the transportation van driver had worked with maintenance regarding the vehicle maintenance and DPS (Department of Public Safety) film. The facility DON revealed the most residents transported on Tuesday and Thursdays are approximately 6 to 7 residents. Further interview with the DON on 06/23/18 at 12:00 p.m. with Facility DON when asked what should the transport van driver do with residents when he arrives at the facility, the DON said to unhook release the resident with the lift and transfer to the unit. Then notify the home/nurse on the unit go back to the van get another resident when the last resident before parking paperwork check. The DON said I assumed they would have a post check, but I do not know what his paperwork is. The DON revealed it should have had a different outcome. The facility DON revealed he (van driver) should have verified the residence were out of the van. 12. In an interview on 06/23/18 at 10:05 a.m. with maintenance director revealed he only knows of a general job description. The maintenance director revealed he is over the maintenance regarding the van. The maintenance director revealed the transport van driver leaves the van running when he leaves the van. The maintenance director revealed regarding training the facility gives the transport van driver a packet of papers and he and I went through the packet. The maintenance director revealed he could not remember in the training packet that checking for residents after a trip was included and he did not remember the training being focused on residents' care related. The maintenance director revealed he has seen residents that had been transported sitting in the common area by the door they go in and out of the van and he knew they had not been taken back to the ERU nurse station. Further interview on 06/23/18 at 2:15 p.m. with facility maintenance director observation of the facility transport van. Maintenance director revealed the facility van is parked in the designated parking space today at this time that the facility transport van driver would have parked the van at noon prior to his lunch on 06/21/18. 13. The recorded Lubbock weather temperature on 06/21/18 at 12:00 p.m. to 6:00 p.m. temp 97 degree. The recorded Lubbock weather temperature on 06/23/18 at 12:00 p.m. to 6:00 p.m. temp 99 degree. On 06/23/18 at 2:15 p.m. the temperature inside the van with in five minutes registered at 110.7° Fahrenheit. Reference: Lubbock International Tx. Weather. https:www.timeanddate.com/weather/usa/Lubbock/historic. 14. In an interview on 06/23/18 at 11:25 a.m. with alert and interviewable Resident #2 (resident #1's roomate), revealed she returned from [MEDICAL TREATMENT] with Resident #1 about 11:30 a.m. Resident #1 revealed the van driver just brought her right inside the building, she had to make her way back to her room he (van driver) just pushed her in the door and he went back out the door. Resident #2 revealed the van was not running, he (van driver) had to pick someone up. 15. In an interview on 06/23/18 at 12:45 p.m. with Resident # 6 revealed on the day of the incident she was very concerned about 12 to 1 pm when Resident #1 had not returned from [MEDICAL TREATMENT]. Resident #6 revealed she asked the therapist and nurse if they had seen Resident #1. They said we are all looking for her. Resident #6 revealed Resident #1 is usually back in her room by 11:30 a.m. Resident #6 revealed she asked them if they had talked to the van driver or Resident #2 that was in the van with Resident #1. Resident #6 revealed she went to therapy that day and she saw Resident #1 and the van driver bringing her in the back door. Resident #1 could not remember what time she went to therapy that day. Resident #1 said ask The therapist (PTA #1) what time he picked her up for therapy. 16. In an interview on 06/23/18 at 12:53 p.m. and 12:58 p.m. with PTA #1 and PTA #2 (physical therapy assistant) revealed on 06/21/18 Resident #1 was picked up in her room at 1:00 p.m. and assisted to the therapy department for treatment. 17. Record review of Resident #1 progress notes dated 06/21/2018 at 13:40 (1:40 p.m.) signed by L,V,N. #1 reflected Resident #1 returning from [MEDICAL TREATMENT]. Upon assessment resident appeared extremely fatigued, upon assessment resident's wheelchair was extremely hot and resident has a temp. of 100.5, B/P (blood pressure), BS (blood sugar) were both WNL (with in normal limits), resident 02 (oxygen) sat (oxygen saturation rate of the blood) was at 55% on RA (room air). 02 applied via NC (nasal cannula) at 3.5 L. 02 rechecked and noted 91% will continue to monitor resident. Record review of Resident #1 progress note dated 06/21/2018 at 13: 55 (1:55p.m.) signed by L.V.N. #1reflected, we checked of Resident temp. (temperature) noted at 98.6 after clothing was removed and resident was given time to cool off. DON notified of all events will continue to monitor. Record review of Resident #1 progress note dated 06/21/2018 at 16:10 (4:16 p.m.) signed by ADON documented called and notified Resident #1, Son, and FNP (facility nurse practitioner) for attending physician, that there was a delay in returning to her room from the bus after [MEDICAL TREATMENT]. The nurse did a full assessment upon arrival to room. Temperature was 100.5 bp 116/62, 101 (pulse), 20, and O2 sats of 55% on RA (room air) nurse immediately applied 3.5 LPM of oxygen via nasal cannula and reassessed O2 sats were up to 91%. She participated in therapy and is currently sitting in room. I spoke with her and she is present. No s/s (signs and symptoms) of any distress or pain noted. No further concerns from the son was notified and the nurse practitioner give any further orders at this time. Record review of Resident #1 progress notes dated 06/21/2018 at 21:01 (9:01p.m.). signed by L.V.N. #1, On 06/21/2018 at 1315 (3:13 p.m.) Resident #1 return from [MEDICAL TREATMENT] brought in via transportation driver in wheelchair, she was noted as very fatigued and hard to keep aroused. the metal on the residence wheelchair was noted as extremely warm to touch and resident skin was also noted as extremely warm to touch. BP (blood pressure) was noted as WNL (within normal limits) 116/60, 02 sats were at 55%. 02 via N/C (nasal cannula) was immediately applied at 3.5 L, stacks did come up to 91%, lungs were CTA (cleared to auscultation) bilateral RR (resident respirations) at 20. Resident FSBG (finger stick blood sugar) was noted at 120. With an elevated body temperature of 100.5. No noted injury to resident skin, resident denies pain radially pulses were both noted as equal bilaterally. 18. Mayo Clinic patient care and health information disease / condition overview: Mayo Clinic: overview heating exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse, a result of body overheating. It's one of the three health risk syndromes, with heat cramps being the mildest and heart [MEDICAL CONDITION] being the most severe. Because of heat exhaustion includes exposure to high temperatures. Symptoms: possible heated job exhaustion signs and symptoms include: Heavy sweating, fatigue, dizziness, witness rapid pulse, low blood pressure upon standing muscle cramps, nausea, headache. Risk factors adults older than 65 are higher risk for heat exhaustion. Prevention: never leave anyone in a parked car. It is not safe to leave a person in a parked car in warm or hot weather. https://www.mayoclinic.org./disease-condition/heat-exhaustion/symptoms-causes /syc- 250 Mayo Clinic hypoxemia (low blood oxygen) - Mayo Clinic Definition [MEDICAL CONDITION] is a new below normal level of oxygen in your blood [MEDICAL CONDITION] is assigned of a problem related to breathing or circulation and may result in various symptoms, such as shortness of breath. Normal [MEDICAL CONDITION] oxygen is approximately 75 to 100 mmHg. Values under 60 mm Hg usually indicate the need for supplemental oxygen. 1998 - (YEAR) foundation for medical education and research (MFMER) https://www.Mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 19. On 06/23/18 at 3:43 p.m., the DON was informed an Immediate Jeopardy. 20. On 06/24/18 at 2:00 p.m. the plan of removal was accepted as follows: This Plan of Removal is in response to the identification of Immediate Jeopardy communicated by the survey team on (MONTH) 23, (YEAR). The Immediate Jeopardy finding was identified in the following area(s): Communication of resident location with non-emergent transportation services - for example family, internal transportation, or external transport to offsite appointments or outings. The Facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiency. Health & Resident Safety Corrective Action On 6/23/2018 a new procedure was initiated for the facility driver, family, or outside vendor transportation service to enhance resident tracking. The transporter will sign the resident out of the facility when going to scheduled appointments, treatments or outings; as well, the nurse will sign them back in via the same form. See attached Exhibit A- Transportation Tracking Log. The Vehicle Safety Policy was amended adding the following: Upon completion of transportation and return of resident to the facility charge nurse, the driver will perform a visual post trip inspection and sign off on the Post Vehicle Inspection Log (Exhibit B) to ensure all residents have been safely removed from the van and the van is ready for the next trip. See attached Exhibit C. Identification Residents which leave the facility for non-emergent reasons have the potential to be affected. Systematic Measures On 6/23/2018, all staff present were educated by NPE, RN staff educator, Center Nurse Executive/DON or designee regarding the new procedure that was initiated for the facility driver, family, or outside vendor transportation service to enhance resident tracking. Education will include how the transporter will sign the resident out of the facility when going to scheduled appointments, treatments or outings; as well, the nurse will sign them back in via the same form. See attached Exhibit A- Transportation Tracking Log All staff will receive training prior to returning to work. All new employees will be educated as part of orientation process. On 6/25/2018 third party contracted vendors which provide medical transfers will be educated prior to transporting facility residents. A letter will be sent to all family members on 6-25-18 and the new process will be reviewed in a special session of the Resident Council on 6-25-18. Quality Assurance and Monitoring The Transportation Tracking Log (Exhibit A) will be monitored daily (M-F) for one month to ensure completion is accurate. Monitoring will continue 2 X weekly for 2 additional months. CED and CNE will report findings of audits in the monthly Performance Improvement (QA&A) meeting monthly for three months or longer until substantial compliance is determined by the Committee. The Performance Improvement Committee consists of but is not limited to the CED, CNE, Assistant Director of Nursing and the Medical Director. 21. On 06/24/18 facility in-service documents and 20 staff interviews related to the plan of removal. The 20 staff interviewed were able to verbalize back in- service information related to the plan of removal. 22. During interviews on 06/24/18 from 10:05 a.m. to 12:35 p.m. with facility staff consisting of 20 staff they revealed they had been trained on abuse and neglect, and the new transportation system. All twenty staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: RNs -2 L.V.N.s - 10 C.N.A - 5 Maintenance director #1 Bookkeeping- 2 The Immediate Jeopardy was removed on 6/24/18, at 2:30 p.m. the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers. A list provided provided by the facility on 6/23/18 revealed 5 other residents transportred by the facility van, Residents' #1, #2, #3, # 4, and #5.

Based on Observation, Interview, and Record Review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with resident ' s plan of care for 1 of 6 residents (resident #1) reviewed for Quality of Care. The resident was admitted to the facility from the hospital and had orders for her to use a [MEDICAL CONDITION] machine to assist her with breathing. The facility failed to ensure Resident #1 ' s [MEDICAL CONDITION] (bi-level positive airway pressure) machine was used, she was later found expired. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not Immediate Jeopardy with a scope identified as isolated. These problems affected resident #1 and had the potential to affect 5 other residents who required breathing assistance. The evidence is as follows: Record review of Resident #1 ' s face sheet dated [DATE] documented she was a [AGE] year old female that was initially admitted to the facility on [DATE]. She had the [DIAGNOSES REDACTED]. Record review of the Provider Investigation Report date reported to the state was [DATE]. It documented an incident date of [DATE] when resident admitted to facility. The resident was discovered on [DATE] at 5:30am in bed not wearing her [MEDICAL CONDITION] machine; unresponsive, she died on [DATE]. The document details that the staff reported the resident did not receive her [MEDICAL CONDITION] upon admission (to be used during sleep). The Administrator felt there was a legitimate belief that neglect was present from nursing by not ensuring the [MEDICAL CONDITION] orders were transcribed and followed through with. The investigation summary documented there were transcription errors from the time of admission by ADON #2, LVN #1, and #2. LVN #3 was the nurse working at the time the [MEDICAL CONDITION] machine was supposed to be used. She told me she saw the machine, but did not use it. The [MEDICAL CONDITION] machine was recognized by LVN #3, but was not used or addressed. This is neglect on not administering the [MEDICAL CONDITION] machine to resident #1. She recognized the machine was sitting next to the bed, but did not use it. Record review of resident #1 ' s hospital History and Physical dated [DATE] that was sent to the facility documented Pt (patient) had Hypercapnia (according to the Merriam-Webster Dictionary Hypercapnia is the presence of an excess amount of carbon [MEDICATION NAME] in the blood). Positive SOB (shortness of breath). Pt has severe [MEDICAL CONDITION] and OSA (obstructive sleep apnea). Pt wears oxygen at all times and [MEDICAL CONDITION] at night. Record review of a document titled Order Detail dated [DATE] that was sent to the facility from the hospital revealed a consult for a [MEDICAL CONDITION] machine and the settings it was to be used on. Record review of resident #1 ' s Nursing Assessment - Initial (Admission) V 3 documented that it was performed on [DATE] at 3:27pm. Resident #1 was admitted to the facility for post-surgery rehabilitation. This assessment documented she used a [MEDICAL CONDITION] machine and a nasal cannula. Record review of resident #1 ' s MAR (Medication Administration Record) and TAR (Treatment administration record) there was no documentation for oxygen or [MEDICAL CONDITION]. Record review of the hand written order for resident #1 revealed [MEDICAL CONDITION] ,[DATE] on at 0130 (1:30am) for 4 hrs (hours) with 02 at 4L (liter). Further review of this order showed that ADON #2 verified these orders via telephone with Physician #1 on [DATE] at 4:00pm. Further review of this document revealed that Physician had signed this order. Attempts to reach ADON #2 were made via telephone on [DATE] at 9:51am and on [DATE] at 11:10am and 12:59pm. There was no answer, left message for a return phone call but never received one. During an interview on [DATE] at 10:42 PM Physician #1 indicated that staff should be following the process for admissions. He said that he did see the [MEDICAL CONDITION] machine sitting on the table on the side of the bed and that he had asked resident #1 if she was on a continuous positive airway pressure ([MEDICAL CONDITION]) and she replied no, that she used a [MEDICAL CONDITION]. Physician #1 stated that resident #1 ' s son had told him that if his mother gets confused to put the [MEDICAL CONDITION] on for a few minutes and that it helped with her Co2 retention. He said he did not specifically give an order for [REDACTED]. He stated that the orders for [MEDICAL CONDITION] are usually for HS and even with naps with a person who has [MEDICAL CONDITION]. He said that order was a weird order; it ' s a cumbersome order, I would never have written that order. During an interview on [DATE] at 1:57 PM LVN #1 indicated resident #1 told her she didn ' t have any complaints. LVN #1 stated resident #1 had her nasal cannula on during CPR (cardiopulmonary resuscitation) conducted at approximately 5:30 AM. During an interview on [DATE] at 12:44 PM Licensed Vocational Nurse (LVN) #5 indicated she was at resident #1 ' s bedside during the code blue. She said that the [MEDICAL CONDITION] mask was not on the resident, only the nasal cannula. During an interview on [DATE] at 12:53 PM LVN #6 indicated that resident #1 did not have her [MEDICAL CONDITION] mask at the time of code blue, only had her cannula on from the concentrator. During an interview on [DATE] at 1:40 PM LVN #2 said that ADON #2 informed her resident #1 used a [MEDICAL CONDITION]; LVN #2 said resident #1 was alert and oriented when they had seen her during their shift. During an interview on [DATE] at 3:09 PM LVN #4 indicated she was resident #1 ' s nurse on the ,[DATE] PM shift on [DATE]. She said no one had given her report for that shift; it was her first time working on the ERU (Express Recovery Unit). LVN #4 stated ADON #2 told her that resident #1 puts her [MEDICAL CONDITION] on around 1:30 AM. She was asked if she reviewed the medical chart for the resident, and she replied no, she was asked if it occurred to her to ask the resident to put on the [MEDICAL CONDITION] when she was going to sleep and she said no ma ' am , she stated she did see the [MEDICAL CONDITION] machine on the table beside the bed. During an interview on [DATE] at 3:25 PM LVN #3 indicated that at around 5:30 AM on [DATE] she went into resident #1 ' s room with the person from the lab company and found her unresponsive, and that ' s when she initiated Code Blue. She stated she didn ' t think the resident had her oxygen on, I was all the way up on her, checking her pulse. She said she wasn ' t told anything in report about residents ' [MEDICAL CONDITION] machine. She said there was not a treatment record for resident #1; otherwise she would have seen the [MEDICAL CONDITION] on it. During an interview on [DATE] at 4:40 PM the Administrator indicated they (nurses) all had a part of it at admission. She said she expected the nurses to verify orders and to transcribe them correctly and that if they saw the machine they should ' ve addressed it. She went on to say that she didn ' t have any documentation showing that the [MEDICAL CONDITION] was used. She said she had documentation to show it arrived at the facility, and that it was picked up but not that it was used. During an interview on [DATE] at 9:05 AM LVN #1 stated ADON #2 gave the unfinished admission paperwork to her and LVN #2. ADON #2 said they needed to get the medication/[MEDICAL CONDITION] orders into the computer and to get consent for a medication. Later the same day LVN #1 called ADON #2 and asked her where she got the orders from; she stated from the History and Physical (H&P) and the home medication list. LVN #1 stated the next morning ([DATE]) when she saw ADON #2 she told her the orders weren ' t finished because she and LVN #2 couldn ' t figure out the medication list. The ADON informed LVN #1 the resident told her she only used her [MEDICAL CONDITION] machine from 1 to 3 AM. LVN #1 was asked if resident #1 had a [MEDICAL CONDITION] machine she said I didn ' t see it on her orders but I did see the machine on the table. During an interview on [DATE] at 9:15 AM ADON #1 indicated that if the facility receives a new admit and they don ' t see orders, that ' s where you should stop admission process. You don ' t go off the H&P or the home med list. If you don ' t have them you reach out to the hospital for report, and d/c orders for meds (medications) and pursue any other orders. When ADON #1 was asked what she thought the staff did wrong she replied honestly I think it was botched from the beginning. First, when we assumed we had the med list and it trickled down from there. There were a lot of errors, I ' m gonna be honest with you. The nurses should have followed through. During an interview on [DATE] at 9:33 AM the Administrator indicated staff failed Resident #1 by not transcribing orders correctly, not following policies, and not complying with their nurse practice act. During an interview on [DATE] at 9:53 AM RN #2 said the ADON #2 brought the [MEDICAL CONDITION] machine into resident #1 ' s room and was showing her and LVN #2 how to use it during their shift (6am to 2pm). ADON #2 also showed LVN #4 how to use it (on the 2pm to 10 pm shift). RN #2 said ADON #2 told her and LVN #2 that the resident had been off the ventilator for 24 hours; the [MEDICAL CONDITION] was tried on the resident while she was at the hospital; it worked for her so then she was sent to the facility. RN #2 was asked if she created the TARs for resident #1 and she replied you know what, I don ' t think I entered hers. I was going to do them the next day. It ' s obvious she was having distress because of her respirations and shortness of breath; she had to pause while talking and take deep breaths. LVN #2 and ADON #2 were aware of this - they were in the room. During an interview on [DATE] at 10:18 AM LVN #2 indicated ADON #2 told her and LVN #1 that resident #1 only used the [MEDICAL CONDITION] machine from 1am to 3 am, and that she would put it on the orders. Record review of the facilities ' procedure titled Bi-level Positive Airway Pressure ([MEDICAL CONDITION])/Continuous Positive Airway Pressure ([MEDICAL CONDITION]) with a revision date of [DATE] documents the instructions on how to set up the machine initially, how to apply settings, how to put the mask on the resident, what to advise the resident of, what to monitor for, how to clean the machine, and what to document concerning the machine. On [DATE] at 4:48 pm an Immediate Jeopardy (IJ) was identified; the Administrator, Assistant Director of Nurses, Nurse Practice Educator (NPE), and Human Resources staff were informed of the IJ due to the above failures. On [DATE] at 10:00am the Administrator and Assistant Director of Nurses (#1) were informed the Plan of Removal was accepted. Plan to Remove Immediate Jeopardy included the following: Quality of Care treatment of [REDACTED].>Abuse/Neglect Quality of Care treatment of [REDACTED].>Corrective Action A change in condition was observed with resident #1 on [DATE]. Licensed nurses immediately initiated life support and emergency services was activated and continued until transition to care of EMTs. The pronouncement of death was made by EMTs in consultation with the emergency room Physician. Identification Charts were audited to ensure [MEDICAL CONDITIONS] , and all equipment were on the MAR by [DATE]. Charts were audited, the DON, to ensure settings for [MEDICAL CONDITION] & [MEDICAL CONDITION] were on the MAR by ,[DATE]/ 16. Charts were audited, the DON, to ensure all orders for [MEDICAL CONDITIONS] & DME were transcribed by ,[DATE]/ 16. Charts were audited, the DON to ensure the admission orders [REDACTED]. Rounds by Administrator on [DATE] revealed no new abuse/neglect. Interviews by Social worker on ,[DATE]/ 16 revealed no new abuse/neglect. Systematic Measures A resident specific equipment identification list of [MEDICAL CONDITIONS] & DME was placed along with a picture of the equipment in the CNA ADL (Activities of Daily Living) book by [DATE]. On [DATE] the licensed nurses (LVNs & RNs) were re-educated by NPE and ADON #1 on [MEDICAL CONDITIONS], and DME. The in service included transcription of equipment to the MARs, and usage/settings of equipment. On [DATE] nursing staff were educated by ADON #1 and the NPE on resident specific equipment identification list placed in the ADL book. On [DATE] a calendar was created to show which nurse was responsible for verifying accurate transcription of admission orders [REDACTED] Abuse/Neglect will be in serviced upon hire (please see attached packet) for all employees. Abuse/Neglect in serviced for all staff on ,[DATE]/ 16. Quality Assurance and Monitoring New Admissions/Re-admissions will be audited utilizing the nursing admission checklist (please see attached) 4 times a week by the Administrator, ADON #1 and/or designee for 3 months to ensure orders are transcribed correctly, physician orders [REDACTED]. Audits will be performed by the Administrator, ADON#1 and/or designee 4 times a week for 3 months to ensure [MEDICAL CONDITIONS], and DME are transcribed correctly to the MARs. ADL books will be reviewed by the Administrator, ADON #1 and/or designee 4 times a week for 3 months to ensure the accuracy of the resident specific equipment identification list. Five interviews from randomized residents will be performed once a week for 4 weeks and reviewed by Social Service, the Administrator and/or designee. The interdisciplinary team reviewed the results of the audits in which compliance was achieved on [DATE] and appropriate corrective measures were put in place. Committee will continue with the performance improvement audits for monitoring of compliance and report results in the next Committee meeting monthly for three months or until compliance is achieved as determined by the Committee. Administrator and Director of Nursing Services will report findings of audits in the monthly Performance Improvement (QA&A) meeting monthly for three months or until substantial compliance is determined by the Committee. The Performance Improvement committee consists but not limited to the Administrator, Director of Nursing, Assistant Director of Nursing and the Medical Director. Observation were conducted on [DATE] between 11:25 PM to 11:37 PM indicated residents(#6, #9, #12, #14 and #15) who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] machines were wearing their machines, there were no concerns. During interview with facility's staff (RN#3, LVNs #13 and #15, CNAs #8 and #13) indicated they were trained on the use of [MEDICAL CONDITION] and [MEDICAL CONDITION] machines. The RNs and LVNs indicated they were trained to ensure the [MEDICAL CONDITION] and [MEDICAL CONDITION] were implemented on their shift, that the setting on these machines were per physician orders, and that they documented on the Medication Administration Records (MARs). Review of the MARs indicated residents (#6, #9, #12, #14 and #15) who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] machines were wearing their machines with settings specified by physician, there were no concerns. The IJ was removed on [DATE] at 10:00 AM. However, the facility remained out of compliance at actual harm that is not Immediate Jeopardy with a scope identified as isolated. compliance at a level of actual harm Record review of a list that was provided by the Administrator documented there were 5 residents who required a [MEDICAL CONDITION] or [MEDICAL CONDITION] machine.

Based on observation, interview and record review, the facility failed to implement their written policy and procedures that prohibit neglect for 1 of 11 residents (Resident #1) reviewed for neglect as evidenced by: The resident was admitted to the facility from the hospital and had orders for her to use a [MEDICAL CONDITION] machine to assist her with breathing. The facility failed to ensure Resident #1 ' s [MEDICAL CONDITION] (bi-level positive airway pressure) machine was used, she was later found expired. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance of actual harm that is not Immediate Jeopardy with a scope identified as isolated. These problems affected resident #1 and had the potential to affect 5 other residents who required breathing assistance The evidence is as follows: Record review of the facilities ' policy and procedure dated [DATE] and titled TX Abuse Prohibition - State of Texas documented the following: Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Purpose: To ensure that Center staff is doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all patients. Record review of the facilities ' procedure titled Bi-level Positive Airway Pressure ([MEDICAL CONDITION])/Continuous Positive Airway Pressure ([MEDICAL CONDITION]) with a revision date of [DATE] documents the instructions on how to set up the machine initially, how to apply settings, how to put the mask on the resident, what to advise the resident of, what to monitor for, how to clean the machine, and what to document concerning the machine. Record review of the facilities ' policy and procedure dated [DATE] and titled Treatments documents the following: Policy: A licensed nurse or medical technician, per state regulations, will perform ordered treatments etc. Purpose: To provide a safe and effective administration of treatments. Record review of Resident #1 ' s face sheet dated [DATE] documented she was a [AGE] year old female that was initially admitted to the facility on [DATE]. She had the [DIAGNOSES REDACTED]. Record review of resident #1 ' s hospital History and Physical dated [DATE] that was sent to the facility documented Pt (patient) had Hypercapnia (according to the Merriam-Webster Dictionary Hypercapnia is the presence of an excess amount of carbon [MEDICATION NAME] in the blood). Positive SOB (shortness of breath). Pt has severe [MEDICAL CONDITION] and OSA (obstructive sleep apnea). Pt wears oxygen at all times and [MEDICAL CONDITION] at night. Record review of a document titled Order Detail dated [DATE] that was sent to the facility from the hospital revealed a consult for a [MEDICAL CONDITION] machine and the settings it was to be used on. Record review of resident #1 ' s Nursing Assessment - Initial (Admission) V 3 documented that it was performed on [DATE] at 3:27pm. Resident #1was admitted to the facility for post-surgery rehabilitation. This assessment documented she used a [MEDICAL CONDITION] machine and a nasal cannula at 4 liters but did not specify a time to be used. Record review of resident #1 ' s MAR (Medication Administration Record) and TAR (Treatment administration record) there was no documentation for oxygen or [MEDICAL CONDITION]. Record review of the hand written order for resident #1 revealed [MEDICAL CONDITION] ,[DATE] on at 0130 (1:30am) for 4 hrs (hours) with 02 at 4L (liter). Further review of this order showed that ADON #2 verified these orders via telephone with Physician #1 on [DATE] at 4:00pm. Further review of this document revealed that Physician #1 had signed this order. During an interview on [DATE] at 10:42 PM Physician #1 indicated that staff should be following the process for admissions. He said that he did see the [MEDICAL CONDITION] machine sitting on the table on the side of the bed and that he had asked resident #1 if she was on a continuous positive airway pressure ([MEDICAL CONDITION]) and she replied no, that she used a [MEDICAL CONDITION]. Physician #1 stated that resident #1 ' s son had told him that if his mother gets confused to put the [MEDICAL CONDITION] on for a few minutes and that it helped with her Co2 retention. He said he did not specifically give an order for [REDACTED]. He stated that the orders for [MEDICAL CONDITION] are usually for HS and even with naps with a person who has [MEDICAL CONDITION]. He said that order was a weird order; it ' s a cumbersome order, I would never have written that order. Record review of the Provider Investigation Report date reported to the state was [DATE]. It documented an incident date of [DATE] when resident admitted to facility. The resident was discovered on [DATE] at 5:30am in bed not wearing her [MEDICAL CONDITION] machine; unresponsive, she died on [DATE]. The document details that the staff reported the resident did not receive her [MEDICAL CONDITION] upon admission (to be used during sleep). The Administrator felt there was a legitimate belief that neglect was present from nursing by not ensuring the [MEDICAL CONDITION] orders were transcribed and followed through with. The investigation summary documented there were transcription errors from the time of admission by ADON #2, LVN #1, and #2. LVN #3 was the nurse working at the time the [MEDICAL CONDITION] machine was supposed to be used. She told me she saw the machine, but did not use it. The [MEDICAL CONDITION] machine was recognized by LVN #3, but was not used or addressed. This is neglect on not administering the [MEDICAL CONDITION] machine to resident #1. She recognized the machine was sitting next to the bed, but did not use it. Record review of resident #1 ' s hospital History and Physical dated [DATE] that was sent to the facility documented Pt (patient) had Hypercapnia (according to the Merriam-Webster Dictionary Hypercapnia is the presence of an excess amount of carbon [MEDICATION NAME] in the blood). Positive SOB (shortness of breath). Pt has severe [MEDICAL CONDITION] and OSA (obstructive sleep apnea). Pt wears oxygen at all times and [MEDICAL CONDITION] at night. Record review of a document titled Order Detail dated [DATE] that was sent to the facility from the hospital revealed a consult for a [MEDICAL CONDITION] machine and the settings it was to be used on. Record review of the hand written order for resident #1 revealed [MEDICAL CONDITION] ,[DATE] on at 0130 (1:30am) for 4 hrs (hours) with 02 at 4L (liter). Further review of this order showed that ADON #2 verified these orders via telephone with Physician #1 on [DATE] at 4:00pm. Further review of this document revealed that Physician had signed this order. Attempts to reach ADON #2 were made via telephone on [DATE] at 9:51am and on [DATE] at 11:10am and 12:59pm. There was no answer, left message for a return phone call but never received one. During an interview on [DATE] at 10:42 PM Physician #1 indicated that staff should be following the process for admissions. He said that he did see the [MEDICAL CONDITION] machine sitting on the table on the side of the bed and that he had asked resident #1 if she was on a continuous positive airway pressure ([MEDICAL CONDITION]) and she replied no, that she used a [MEDICAL CONDITION]. Physician #1 stated that resident #1 ' s son had told him that if his mother gets confused to put the [MEDICAL CONDITION] on for a few minutes and that it helped with her Co2 retention. He said he did not specifically give an order for [REDACTED]. He stated that the orders for [MEDICAL CONDITION] are usually for HS and even with naps with a person who has [MEDICAL CONDITION]. He said that order was a weird order; it ' s a cumbersome order, I would never have written that order. During an interview on [DATE] at 1:57 PM LVN #1 indicated resident #1 told her she didn ' t have any complaints. LVN #1 stated resident #1 had her nasal cannula on during CPR (cardiopulmonary resuscitation) conducted at approximately 5:30 AM. During an interview on [DATE] at 12:44 PM Licensed Vocational Nurse (LVN) #5 indicated she was at resident #1 ' s bedside during the code blue. She said that the [MEDICAL CONDITION] mask was not on the resident, only the nasal cannula. During an interview on [DATE] at 12:53 PM LVN #6 indicated that resident #1 did not have her [MEDICAL CONDITION] mask at the time of code blue, only had her cannula on from the concentrator. During an interview on [DATE] at 1:40 PM LVN #2 said that ADON #2 informed her resident #1 used a [MEDICAL CONDITION]; LVN #2 said resident #1 was alert and oriented when they had seen her during their shift. During an interview on [DATE] at 3:09 PM LVN #4 indicated she was resident #1 ' s nurse on the ,[DATE] PM shift on [DATE]. She said no one had given her report for that shift; it was her first time working on the ERU (Express Recovery Unit). LVN #4 stated ADON #2 told her that resident #1 puts her [MEDICAL CONDITION] on around 1:30 AM. She was asked if she reviewed the medical chart for the resident, and she replied no, she was asked if it occurred to her to ask the resident to put on the [MEDICAL CONDITION] when she was going to sleep and she said no ma ' am , she stated she did see the [MEDICAL CONDITION] machine on the table beside the bed. During an interview on [DATE] at 3:25 PM LVN #3 indicated that at around 5:30 AM on [DATE] she went into resident #1 ' s room with the person from the lab company and found her unresponsive, and that ' s when she initiated Code Blue. She stated she didn ' t think the resident had her oxygen on, I was all the way up on her, checking her pulse. She said she wasn ' t told anything in report about residents ' [MEDICAL CONDITION] machine. She said there was not a treatment record for resident #1; otherwise she would have seen the [MEDICAL CONDITION] on it. During an interview on [DATE] at 4:40 PM the Administrator indicated they (nurses) all had a part of it at admission. She said she expected the nurses to verify orders and to transcribe them correctly and that if they saw the machine they should ' ve addressed it. She went on to say that she didn ' t have any documentation showing that the [MEDICAL CONDITION] was used. She said she had documentation to show it arrived at the facility, and that it was picked up but not that it was used. During an interview on [DATE] at 9:05 AM LVN #1 stated ADON #2 gave the unfinished admission paperwork to her and LVN #2. ADON #2 said they needed to get the medication/[MEDICAL CONDITION] orders into the computer and to get consent for a medication. Later the same day LVN #1 called ADON #2 and asked her where she got the orders from; she stated from the History and Physical (H&P) and the home medication list. LVN #1 stated the next morning ([DATE]) when she saw ADON #2 she told her the orders weren ' t finished because she and LVN #2 couldn ' t figure out the medication list. The ADON informed LVN #1 the resident told her she only used her [MEDICAL CONDITION] machine from 1 to 3 AM. LVN #1 was asked if resident #1 had a [MEDICAL CONDITION] machine she said I didn ' t see it on her orders but I did see the machine on the table. During an interview on [DATE] at 9:15 AM ADON #1 indicated that if the facility receives a new admit and they don ' t see orders, that ' s where you should stop admission process. You don ' t go off the H&P or the home med list. If you don ' t have them you reach out to the hospital for report, and d/c orders for meds (medications) and pursue any other orders. When ADON #1 was asked what she thought the staff did wrong she replied honestly I think it was botched from the beginning. First, when we assumed we had the med list and it trickled down from there. There were a lot of errors, I ' m gonna be honest with you. The nurses should have followed through. During an interview on [DATE] at 9:33 AM the Administrator indicated staff failed Resident #1 by not transcribing orders correctly, not following policies, and not complying with their nurse practice act. During an interview on [DATE] at 9:53 AM RN #2 said the ADON #2 brought the [MEDICAL CONDITION] machine into resident #1 ' s room and was showing her and LVN #2 how to use it during their shift (6am to 2pm). ADON #2 also showed LVN #4 how to use it (on the 2pm to 10 pm shift). RN #2 said ADON #2 told her and LVN #2 that the resident had been off the ventilator for 24 hours; the [MEDICAL CONDITION] was tried on the resident while she was at the hospital; it worked for her so then she was sent to the facility. RN #2 was asked if she created the TARs for resident #1 and she replied you know what, I don ' t think I entered hers. I was going to do them the next day. It ' s obvious she was having distress because of her respirations and shortness of breath; she had to pause while talking and take deep breaths. LVN #2 and ADON #2 were aware of this - they were in the room. During an interview on [DATE] at 10:18 AM LVN #2 indicated ADON #2 told her and LVN #1 that resident #1 only used the [MEDICAL CONDITION] machine from 1am to 3 am, and that she would put it on the orders. On [DATE] at 4:48 pm an Immediate Jeopardy (IJ) was identified; the Administrator, Assistant Director of Nurses, Nurse Practice Educator (NPE), and Human Resources staff were informed of the IJ due to the above failures. On [DATE] at 10:00am the Administrator and Assistant Director of Nurses (#1) were informed the Plan of Removal was accepted. Plan to Remove Immediate Jeopardy included the following: Quality of Care treatment of [REDACTED].>Abuse/Neglect Quality of Care treatment of [REDACTED].>Corrective Action A change in condition was observed with resident #1 on [DATE]. Licensed nurses immediately initiated life support and emergency services was activated and continued until transition to care of EMTs. The pronouncement of death was made by EMTs in consultation with the emergency room Physician. Identification Charts were audited to ensure [MEDICAL CONDITIONS] , and all equipment were on the MAR by [DATE]. Charts were audited, the DON, to ensure settings for [MEDICAL CONDITION] & [MEDICAL CONDITION] were on the MAR by ,[DATE]/ 16. Charts were audited, the DON, to ensure all orders for [MEDICAL CONDITIONS] & DME were transcribed by ,[DATE]/ 16. Charts were audited, the DON to ensure the admission orders [REDACTED]. Rounds by Administrator on [DATE] revealed no new abuse/neglect. Interviews by Social worker on ,[DATE]/ 16 revealed no new abuse/neglect. Systematic Measures A resident specific equipment identification list of [MEDICAL CONDITIONS] & DME was placed along with a picture of the equipment in the CNA ADL (Activities of Daily Living) book by [DATE]. On [DATE] the licensed nurses (LVNs & RNs) were re-educated by NPE and ADON #1 on [MEDICAL CONDITIONS], and DME. The in service included transcription of equipment to the MARs, and usage/settings of equipment. On [DATE] nursing staff were educated by ADON #1 and the NPE on resident specific equipment identification list placed in the ADL book. On [DATE] a calendar was created to show which nurse was responsible for verifying accurate transcription of admission orders [REDACTED] Abuse/Neglect will be in serviced upon hire (please see attached packet) for all employees. Abuse/Neglect in serviced for all staff on ,[DATE]/ 16. Quality Assurance and Monitoring New Admissions/Re-admissions will be audited utilizing the nursing admission checklist (please see attached) 4 times a week by the Administrator, ADON #1 and/or designee for 3 months to ensure orders are transcribed correctly, physician orders [REDACTED]. Audits will be performed by the Administrator, ADON#1 and/or designee 4 times a week for 3 months to ensure [MEDICAL CONDITIONS], and DME are transcribed correctly to the MARs. ADL books will be reviewed by the Administrator, ADON #1 and/or designee 4 times a week for 3 months to ensure the accuracy of the resident specific equipment identification list. Five interviews from randomized residents will be performed once a week for 4 weeks and reviewed by Social Service, the Administrator and/or designee. The interdisciplinary team reviewed the results of the audits in which compliance was achieved on [DATE] and appropriate corrective measures were put in place. Committee will continue with the performance improvement audits for monitoring of compliance and report results in the next Committee meeting monthly for three months or until compliance is achieved as determined by the Committee. Administrator and Director of Nursing Services will report findings of audits in the monthly Performance Improvement (QA&A) meeting monthly for three months or until substantial compliance is determined by the Committee. The Performance Improvement committee consists but not limited to the Administrator, Director of Nursing, Assistant Director of Nursing and the Medical Director. Observation were conducted on [DATE] between 11:25 PM to 11:37 PM indicated residents(#6, #9, #12, #14 and #15) who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] machines were wearing their machines, there were no concerns. During interview with facility's staff (RN#3, LVNs #13 and #15, CNAs #8 and #13) indicated they were trained on the use of [MEDICAL CONDITION] and [MEDICAL CONDITION] machines. The RNs and LVNs indicated they were trained to ensure the [MEDICAL CONDITION] and [MEDICAL CONDITION] were implemented on their shift, that the setting on these machines were per physician orders, and that they documented on the Medication Administration Records (MARs). Review of the MARs indicated residents (#6, #9, #12, #14 and #15) who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] machines were wearing their machines with settings specified by physician, there were no concerns. The IJ was removed on [DATE] at 10:00 AM. However, the facility remained out of compliance at actual harm that is not Immediate Jeopardy with a scope identified as isolated. Record review of a list that was provided by the Administrator documented there were 5 residents who required a [MEDICAL CONDITION] or [MEDICAL CONDITION] machine.

Based on observation, interview and record review, the facility failed to implement their policy and procedures that prohibit neglect for 1 of 11 residents (Resident #1) reviewed for neglect as evidenced by: The resident was admitted to the facility from the hospital and had orders for her to use a [MEDICAL CONDITION] machine to assist her with breathing. The facility failed to ensure Resident #1 ' s [MEDICAL CONDITION] (bi-level positive airway pressure) machine was used, she was later found expired. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance of actual harm that is not Immediate Jeopardy with a scope identified as isolated. These problems affected resident #1 and had the potential to affect 5 other residents who required breathing assistance. The evidence is as follows: Record review of Resident #1 ' s face sheet dated [DATE] documented she was a [AGE] year old female that was initially admitted to the facility on [DATE]. She had the [DIAGNOSES REDACTED]. Record review of the Provider Investigation Report date reported to the state was [DATE]. It documented an incident date of [DATE] when resident admitted to facility. The resident was discovered on [DATE] at 5:30am in bed not wearing her [MEDICAL CONDITION] machine; unresponsive, she died on [DATE]. The document details that the staff reported the resident did not receive her [MEDICAL CONDITION] upon admission (to be used during sleep). The Administrator felt there was a legitimate belief that neglect was present from nursing by not ensuring the [MEDICAL CONDITION] orders were transcribed and followed through with. The investigation summary documented there were transcription errors from the time of admission by ADON #2, LVN #1, and #2. LVN #3 was the nurse working at the time the [MEDICAL CONDITION] machine was supposed to be used. She told me she saw the machine, but did not use it. The [MEDICAL CONDITION] machine was recognized by LVN #3, but was not used or addressed. This is neglect on not administering the [MEDICAL CONDITION] machine to resident #1. She recognized the machine was sitting next to the bed, but did not use it. Record review of resident #1 ' s hospital History and Physical dated [DATE] that was sent to the facility documented Pt (patient) had Hypercapnia (according to the Merriam-Webster Dictionary Hypercapnia is the presence of an excess amount of carbon [MEDICATION NAME] in the blood). Positive SOB (shortness of breath). Pt has severe [MEDICAL CONDITION] and OSA (obstructive sleep apnea). Pt wears oxygen at all times and [MEDICAL CONDITION] at night. Record review of a document titled Order Detail dated [DATE] that was sent to the facility from the hospital revealed a consult for a [MEDICAL CONDITION] machine and the settings it was to be used on. Record review of resident #1 ' s Nursing Assessment - Initial (Admission) V 3 documented that it was performed on [DATE] at 3:27pm. Resident #1 was admitted to the facility for post-surgery rehabilitation. This assessment documented she used a [MEDICAL CONDITION] machine and a nasal cannula. Record review of resident #1 ' s MAR (Medication Administration Record) and TAR (Treatment administration record) there was no documentation for oxygen or [MEDICAL CONDITION]. Record review of the hand written order for resident #1 revealed [MEDICAL CONDITION] ,[DATE] on at 0130 (1:30am) for 4 hrs (hours) with 02 at 4L (liter). Further review of this order showed that ADON #2 verified these orders via telephone with Physician #1 on [DATE] at 4:00pm. Further review of this document revealed that Physician had signed this order. Attempts to reach ADON #2 were made via telephone on [DATE] at 9:51am and on [DATE] at 11:10am and 12:59pm. There was no answer, left message for a return phone call but never received one. During an interview on [DATE] at 10:42 PM Physician #1 indicated that staff should be following the process for admissions. He said that he did see the [MEDICAL CONDITION] machine sitting on the table on the side of the bed and that he had asked resident #1 if she was on a continuous positive airway pressure ([MEDICAL CONDITION]) and she replied no, that she used a [MEDICAL CONDITION]. Physician #1 stated that resident #1 ' s son had told him that if his mother gets confused to put the [MEDICAL CONDITION] on for a few minutes and that it helped with her Co2 retention. He said he did not specifically give an order for [REDACTED]. He stated that the orders for [MEDICAL CONDITION] are usually for HS and even with naps with a person who has [MEDICAL CONDITION]. He said that order was a weird order; it ' s a cumbersome order, I would never have written that order. During an interview on [DATE] at 1:57 PM LVN #1 indicated resident #1 told her she didn ' t have any complaints. LVN #1 stated resident #1 had her nasal cannula on during CPR (cardiopulmonary resuscitation) conducted at approximately 5:30 AM. During an interview on [DATE] at 12:44 PM Licensed Vocational Nurse (LVN) #5 indicated she was at resident #1 ' s bedside during the code blue. She said that the [MEDICAL CONDITION] mask was not on the resident, only the nasal cannula. During an interview on [DATE] at 12:53 PM LVN #6 indicated that resident #1 did not have her [MEDICAL CONDITION] mask at the time of code blue, only had her cannula on from the concentrator. During an interview on [DATE] at 1:40 PM LVN #2 said that ADON #2 informed her resident #1 used a [MEDICAL CONDITION]; LVN #2 said resident #1 was alert and oriented when they had seen her during their shift. During an interview on [DATE] at 3:09 PM LVN #4 indicated she was resident #1 ' s nurse on the ,[DATE] PM shift on [DATE]. She said no one had given her report for that shift; it was her first time working on the ERU (Express Recovery Unit). LVN #4 stated ADON #2 told her that resident #1 puts her [MEDICAL CONDITION] on around 1:30 AM. She was asked if she reviewed the medical chart for the resident, and she replied no, she was asked if it occurred to her to ask the resident to put on the [MEDICAL CONDITION] when she was going to sleep and she said no ma ' am , she stated she did see the [MEDICAL CONDITION] machine on the table beside the bed. During an interview on [DATE] at 3:25 PM LVN #3 indicated that at around 5:30 AM on [DATE] she went into resident #1 ' s room with the person from the lab company and found her unresponsive, and that ' s when she initiated Code Blue. She stated she didn ' t think the resident had her oxygen on, I was all the way up on her, checking her pulse. She said she wasn ' t told anything in report about residents ' [MEDICAL CONDITION] machine. She said there was not a treatment record for resident #1; otherwise she would have seen the [MEDICAL CONDITION] on it. During an interview on [DATE] at 4:40 PM the Administrator indicated they (nurses) all had a part of it at admission. She said she expected the nurses to verify orders and to transcribe them correctly and that if they saw the machine they should ' ve addressed it. She went on to say that she didn ' t have any documentation showing that the [MEDICAL CONDITION] was used. She said she had documentation to show it arrived at the facility, and that it was picked up but not that it was used. During an interview on [DATE] at 9:05 AM LVN #1 stated ADON #2 gave the unfinished admission paperwork to her and LVN #2. ADON #2 said they needed to get the medication/[MEDICAL CONDITION] orders into the computer and to get consent for a medication. Later the same day LVN #1 called ADON #2 and asked her where she got the orders from; she stated from the History and Physical (H&P) and the home medication list. LVN #1 stated the next morning ([DATE]) when she saw ADON #2 she told her the orders weren ' t finished because she and LVN #2 couldn ' t figure out the medication list. The ADON informed LVN #1 the resident told her she only used her [MEDICAL CONDITION] machine from 1 to 3 AM. LVN #1 was asked if resident #1 had a [MEDICAL CONDITION] machine she said I didn ' t see it on her orders but I did see the machine on the table. During an interview on [DATE] at 9:15 AM ADON #1 indicated that if the facility receives a new admit and they don ' t see orders, that ' s where you should stop admission process. You don ' t go off the H&P or the home med list. If you don ' t have them you reach out to the hospital for report, and d/c orders for meds (medications) and pursue any other orders. When ADON #1 was asked what she thought the staff did wrong she replied honestly I think it was botched from the beginning. First, when we assumed we had the med list and it trickled down from there. There were a lot of errors, I ' m gonna be honest with you. The nurses should have followed through. During an interview on [DATE] at 9:33 AM the Administrator indicated staff failed Resident #1 by not transcribing orders correctly, not following policies, and not complying with their nurse practice act. During an interview on [DATE] at 9:53 AM RN #2 said the ADON #2 brought the [MEDICAL CONDITION] machine into resident #1 ' s room and was showing her and LVN #2 how to use it during their shift (6am to 2pm). ADON #2 also showed LVN #4 how to use it (on the 2pm to 10 pm shift). RN #2 said ADON #2 told her and LVN #2 that the resident had been off the ventilator for 24 hours; the [MEDICAL CONDITION] was tried on the resident while she was at the hospital; it worked for her so then she was sent to the facility. RN #2 was asked if she created the TARs for resident #1 and she replied you know what, I don ' t think I entered hers. I was going to do them the next day. It ' s obvious she was having distress because of her respirations and shortness of breath; she had to pause while talking and take deep breaths. LVN #2 and ADON #2 were aware of this - they were in the room. During an interview on [DATE] at 10:18 AM LVN #2 indicated ADON #2 told her and LVN #1 that resident #1 only used the [MEDICAL CONDITION] machine from 1am to 3 am, and that she would put it on the orders. Record review of the facilities ' procedure titled Bi-level Positive Airway Pressure ([MEDICAL CONDITION])/Continuous Positive Airway Pressure ([MEDICAL CONDITION]) with a revision date of [DATE] documents the instructions on how to set up the machine initially, how to apply settings, how to put the mask on the resident, what to advise the resident of, what to monitor for, how to clean the machine, and what to document concerning the machine. On [DATE] at 4:48 pm an Immediate Jeopardy (IJ) was identified; the Administrator, Assistant Director of Nurses, Nurse Practice Educator (NPE), and Human Resources staff were informed of the IJ due to the above failures. On [DATE] at 10:00am the Administrator and Assistant Director of Nurses (#1) were informed the Plan of Removal was accepted. Plan to Remove Immediate Jeopardy included the following: Quality of Care treatment of [REDACTED].>Abuse/Neglect Quality of Care treatment of [REDACTED].>Corrective Action A change in condition was observed with resident #1 on [DATE]. Licensed nurses immediately initiated life support and emergency services was activated and continued until transition to care of EMTs. The pronouncement of death was made by EMTs in consultation with the emergency room Physician. Identification Charts were audited to ensure [MEDICAL CONDITIONS] , and all equipment were on the MAR by [DATE]. Charts were audited, the DON, to ensure settings for [MEDICAL CONDITION] & [MEDICAL CONDITION] were on the MAR by ,[DATE]/ 16. Charts were audited, the DON, to ensure all orders for [MEDICAL CONDITIONS] & DME were transcribed by ,[DATE]/ 16. Charts were audited, the DON to ensure the admission orders [REDACTED]. Rounds by Administrator on [DATE] revealed no new abuse/neglect. Interviews by Social worker on ,[DATE]/ 16 revealed no new abuse/neglect. Systematic Measures A resident specific equipment identification list of [MEDICAL CONDITIONS] & DME was placed along with a picture of the equipment in the CNA ADL (Activities of Daily Living) book by [DATE]. On [DATE] the licensed nurses (LVNs & RNs) were re-educated by NPE and ADON #1 on [MEDICAL CONDITIONS], and DME. The in service included transcription of equipment to the MARs, and usage/settings of equipment. On [DATE] nursing staff were educated by ADON #1 and the NPE on resident specific equipment identification list placed in the ADL book. On [DATE] a calendar was created to show which nurse was responsible for verifying accurate transcription of admission orders [REDACTED] Abuse/Neglect will be in serviced upon hire (please see attached packet) for all employees. Abuse/Neglect in serviced for all staff on ,[DATE]/ 16. Quality Assurance and Monitoring New Admissions/Re-admissions will be audited utilizing the nursing admission checklist (please see attached) 4 times a week by the Administrator, ADON #1 and/or designee for 3 months to ensure orders are transcribed correctly, physician orders [REDACTED]. Audits will be performed by the Administrator, ADON#1 and/or designee 4 times a week for 3 months to ensure [MEDICAL CONDITIONS], and DME are transcribed correctly to the MARs. ADL books will be reviewed by the Administrator, ADON #1 and/or designee 4 times a week for 3 months to ensure the accuracy of the resident specific equipment identification list. Five interviews from randomized residents will be performed once a week for 4 weeks and reviewed by Social Service, the Administrator and/or designee. The interdisciplinary team reviewed the results of the audits in which compliance was achieved on [DATE] and appropriate corrective measures were put in place. Committee will continue with the performance improvement audits for monitoring of compliance and report results in the next Committee meeting monthly for three months or until compliance is achieved as determined by the Committee. Administrator and Director of Nursing Services will report findings of audits in the monthly Performance Improvement (QA&A) meeting monthly for three months or until substantial compliance is determined by the Committee. The Performance Improvement committee consists but not limited to the Administrator, Director of Nursing, Assistant Director of Nursing and the Medical Director. Observation were conducted on [DATE] between 11:25 PM to 11:37 PM indicated residents(#6, #9, #12, #14 and #15) who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] machines were wearing their machines, there were no concerns. During interview with facility's staff (RN#3, LVNs #13 and #15, CNAs #8 and #13) indicated they were trained on the use of [MEDICAL CONDITION] and [MEDICAL CONDITION] machines. The RNs and LVNs indicated they were trained to ensure the [MEDICAL CONDITION] and [MEDICAL CONDITION] were implemented on their shift, that the setting on these machines were per physician orders, and that they documented on the Medication Administration Records (MARs). Review of the MARs indicated residents (#6, #9, #12, #14 and #15) who utilized [MEDICAL CONDITION] and [MEDICAL CONDITION] machines were wearing their machines with settings specified by physician, there were no concerns. The IJ was removed on [DATE] at 10:00 AM. However, the facility remained out of compliance at actual harm that is not Immediate Jeopardy with a scope identified as isolated. Record review of a list that was provided by the Administrator documented there were 5 residents who required a [MEDICAL CONDITION] or [MEDICAL CONDITION] machine.

Based on observation, interview, and record review, it was determined the facility failed to ensure that a resident who had a pressure ulcer receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for one (Resident #1) of five residents, who was reviewed for skin conditions. The facility failed to keep Resident #1's unstageable pressure ulcer covered and free of contamination. Resident #1's unstageable pressure ulcer deteriorated from 07/30/15 with measurements of 3.0 cm x 3.0 cm x depth (not able to be determined due to eschar) to 4.0 cm x 3.5 cm x depth (not able to be determined due to slough) on 08/06/15. These failures could affect the seven residents with pressure ulcers by placing them at risk for deteriorating pressure ulcers, infection and pain. Findings included: Resident #1's MDS assessment, dated 06/15/15 reflected the resident was a [AGE] year-old-male, admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #1 required extensive assistance in bed mobility, total assistance of two staff members for transfers, dressing, and personal hygiene, had a urinary catheter and was always incontinent of bowel. The assessment further reflected Resident #1 was at risk for pressure ulcer development and had a Stage III pressure ulcer measuring 2.0 cm x 1.5 cm x 0.3 (length,width,depth) with slough at the wound bed. Review of Resident #1's Comprehensive Plan of Care, dated 01/27/15, revealed the resident was at high risk for pressure ulcers and identified a pressure ulcer on Resident #1's toe. There was no mention or revised care plan for Resident #1's Stage III pressure ulcer on his sacrum. Review of the wound care evaluation, dated 06/23/15 revealed Resident #1's sacral pressure ulcer's onset date was 02/26/15. The pressure ulcer measurement on 06/23/15 was 2.50 cm x 1.0 cm x 0.3 cm. Comments included: .daily dressing due to incontinence that compromises dressing integrity at least every 24 hours and increases risk of wound bed contamination. The facility's Wound Healing Progress Report with transaction dates from 04/30/15 through 07/30/15 reflected Resident #1's sacral wound measurement went from 2.0 cm x 0.80 cm x 0.30 cm on 07/23/15 to 3.0 cm x 3.0 cm x unstageable due to eschar on 07/30/15. Resident #1's August 2015 physician's orders [REDACTED]. Resident #1's August 2015 Treatment Nurse Administration Record reflected the resident was receiving wound care to his sacrum at least once a day. There was no indication that there were any additional dressing changes. On 08/06/15 at 9:00 AM, CNA C was observed preparing to perform incontinent care for Resident #1. When CNA C removed the resident brief the resident had a large soft BM that went up and into the wound bed of the pressure ulcer. There was no dressing on the resident or in the brief. CNA C said that she did not notice if the resident had a dressing when she got him up for breakfast. CNA C further stated she would inform her charge nurse but the charge nurse had told her in the past that either it was not the resident ' s treatment day or she would notify the treatment nurse. On 08/06/15 at 9:30 AM the treatment nurse, LVN D, provided wound care for Resident #1. At this time LVN D's measurement of the pressure ulcer was, 4.0 cm x 3.5 cm x unstageable due to slough in the wound bed. LVN D admitted that the pressure ulcer was worse than the last measurement he took six days prior. He said he was the week day treatment nurse and normally worked Monday through Friday, however he was off last Friday so the last measurement and treatment he performed was 07/30/15. LVN D further stated that week the last time he changed Resident #1's dressing was approximately 5:30 AM on 08/05/15. He said he was in a training class the rest of the day on 08/05/15 and went straight to his training class that morning. LVN D said the charge nurses usually notified him if a dressing came off and he replaced it but he was not made aware Resident #1's dressing was off. During an interview on 08/06/15 at 4:30 PM with ADM and DON, the Administrator and DON stated they would continue to train and re-train staff. The ADM also stated that the former DON did not allow the charge nurses to do any wound care and that this was not current practice of the facility. The facility's current Pressure Ulcer Prevention & Management Policy and Procedure, revised 10/15/14, reflected: Policy: .Any resident who has pressure ulcers will receive the necessary treatment and services to promote healing, prevent infections, prevent new ulcers from development. The Focused Survey Facility Worksheet (worksheet #1) filled out by the DON on 08/05/15 reflected seven residents were identified with pressure ulcers.