Every finding on record at Avir at Lindale

Based on observation, interview, and record review the facility failed to have food available to meet the nutritional needs in accordance with established guidelines for 1 of 1 lunch meals reviewed. The facility failed to follow the posted menu on 6/10/26. The facility failed to ensure the kitchen staff properly portioned the spaghetti served during lunch on 6/10/26. The facility failed to ensure kitchen staff provided all residents with the same portion of mixed vegetables on 6/10/26. The facility failed to ensure the facility did not run out of garlic bread during lunch on 6/10/26. These failures could place residents at risk of decreased quality of life, poor intake, and/or weight loss. Findings included: During an observation on 6/10/26 at 11:28 a.m. the board in the resident dining room indicated the following meal was to be served for lunch: spaghetti, roasted cauliflower, garlic toast, and fresh fruit cup. During an observation on 6/10/26 at 11:30 a.m. lunch trays were being prepared. Lunch was spaghetti (sauce and noodles mixed together), mixed vegetables, garlic bread, and a fruit cup. During lunch service the spaghetti portions were not measured, the cook used tongs and put 2-3 tongs full of spaghetti on the trays. The kitchen ran out of garlic bread during lunch service and part of the 200 hall, and all of the 300 and 400 halls did not receive any garlic bread. The 300 hall trays were the last prepared and while preparing the 300 hall trays kitchen staff started giving some residents only a half scoop of mixed vegetables and less spaghetti. [NAME] G began heating up carrots on the stove. Record review of the Dining Manager's recipes for Spaghetti with Ground Meatballs and Sauce indicated the portion size for a regular portion was a #12 scoop of ground meatballs and sauce and 4oz of pasta. During an interview with the Administrator on 6/10/26 at 12:35 p.m. the Administrator said he expected there to be enough garlic bread for all the residents in the facility. The Administrator said the spaghetti should have been measured for the correct portion size. The Administrator said all food on the trays should be the same portions for all residents unless indicated otherwise by the residents' orders. The Administrator said the importance of ensuring every resident got the same meal and what was offered on the menu was a resident right. The Administrator said the importance of the food being properly portioned was to ensure residents' nutritional needs were being met. During an interview on 6/10/26 at 1:48 p.m. [NAME] G said he had worked at the facility for approximately a year and 3 months. [NAME] G said he was trained at the facility by a previous cook. [NAME] G said he did not know why but it was probably a mix up that they used mixed vegetables for the lunch service instead of the roasted cauliflower that was on the menu. [NAME] G said when serving spaghetti, they could use a scoop or tongs. [NAME] G verified the spaghetti recipe did not indicate the use of tongs for serving. [NAME] G said he used tongs to serve the spaghetti because when he used the scoop some of the food would fall out and the residents were not getting a proper portion. [NAME] G said using the tongs he knew the residents were getting plenty of spaghetti and probably more than a regular portion. [NAME] G said they were running out of mixed vegetables during lunch service and that some residents were not receiving a full scoop of mixed vegetables. [NAME] G said they had used 4 cans of mixed vegetables which was usually plenty, but the facility had got several new residents, and 4 cans was not enough this time. [NAME] G said they did run out of garlic bread during lunch service and that was because the miss counted. [NAME] G said he did not have an answer as to the importance of proper portion size and not running out of something on the menu. [NAME] G said the importance of following the posted menu was to stay on task and for the food order. Record review of the facility's Standarized Recipes policy dated 2023 indicated, Standarized recipes will be used when preparing menu items. 1. Standarized recipes (in appropriate portion sizes) for planned menu items will be maintained in the facility .3. Cooks/chefs are expected to use and follow the recipes provided. Record review of the facility's Portion Control policy dated 2023 indicated, Individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served.3. Food should be served with ladles scoops, spoodles (a hybrid kitchen utensil that combines the features of a traditional spoon and a ladle), and spoons of standard sizes. Scales should be used as needed to weigh meat portions. Scoops should be leveled off (not overflowing) for the most accurate portion sizes. a. Portions that are too small result in the individual not receiving the nutrients needed. b. Portions that are too large increase food costs as well as providing the individual with more food than needed.Serving Utensils #12 scoop=1/3 cup=2.67 ounces.

Based on interview and record review, the facility failed to provide personal privacy when providing care for 1 of 9 (Resident #3) residents reviewed for privacy. The facility did not ensure CNA D and CNA E pulled the privacy curtain while providing incontinent care for Resident #3 on [DATE]. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.Findings included: Record review of the face sheet dated [DATE] indicated Resident #3 was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Myasthenia Gravis (a condition that causes weakness in the voluntary muscles), lack of coordination, cognitive communication deficit (an impairment in communication), and weakness. Record review of the MDS dated [DATE] indicated Resident #3 sometimes understood others and was usually understood by others. The MDS indicated Resident #3 did not have a BIMS score. The MDS indicated Resident #3 was dependent on staff for toileting. Record review of the care plan revised [DATE] indicated Resident #3 had an ADL self-care performance deficit related to confusion, fatigue, impaired balance, and limited mobility. Record review of a progress note dated [DATE] indicated Resident #3 expired in the facility. Record review of video footage from electronic monitoring indicated on [DATE] at 5:59 pm 2 CNAs performed incontinent care on Resident #3. The video footage indicated the CNAs did not pull the privacy curtain during incontinent care. The video footage indicated Resident #3's roommate was sitting up in bed while incontinent care was being provided on Resident #3. The video footage indicated the CNAs spoke with Resident #3's roommate while providing care. During an interview on [DATE] at 12:52 p.m. CNA E said she had worked the night shift on [DATE]. CNA E said Resident #3 was already in bed when she started her shift on [DATE]. During an interview on [DATE] at 1:33. CNA D said she had worked the night shift on [DATE]. CNA E said Resident #3 was already in bed when she started her shift on [DATE]. During an interview on [DATE] at 3:13 p.m. the DON identified CNA D and CNA E as the CNAs in the video dated [DATE]. The DON said the CNAs should have pulled the privacy curtain while providing incontinent care and their attention should have been on Resident #3 and not speaking with his roommate during incontinent care. The DON said the importance of providing privacy and giving their attention to the residents during incontinent care was for dignity and respect. During an interview on [DATE] at 9:52 a.m. CNA E said she was unable to come to the facility to review the video dated [DATE]. During an interview on [DATE] at 10:05 a.m. CNA D said she was one of the CNAs in the video dated [DATE]. CNA D said she did not know why the privacy curtain was not pulled during incontinent care in the video that she must have forgotten to pull the privacy curtain. CNA D said they were not engaging with Resident #3 during care and talking to his roommate because Resident #3 did not talk and his roommate was talking to them. CNA E said the importance of engaging with the resident during care was in case the resident needed something or wanted something. CNA E said the importance in ensuring the privacy curtain was pulled when providing care was for dignity. Record review of the facility's Resident Rights policy revised 2/2021 indicated, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.t. privacy and confidentiality. Record review of the facility's Dignity policy revised 2/2021 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Resident are treated with dignity and respect at all times. 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 4 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1's mouth, chin, and neck were cleaned on 6/9/26. The failure could place residents at risk of not receiving services/care and decreased quality of life.Findings Include: Record review of the face sheet dated 6/9/26 indicated Resident #1 was an [AGE] year-old female that was re-admitted to the facility on [DATE] with diagnoses including encephalopathy (any disease damage, or malfunction of the brain that alters its structure or function), cognitive communication deficit (an impairment in communication), dementia, intellectual disabilities, and anxiety. Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 04 and was severely cognitively impaired. The MDS indicated Resident #1 required partial/moderate assistance with personal hygiene. Record review of the care plan last revised on 2/10/26 indicated Resident #1 had potential for an ADL self-care performance deficit. During an observation and interview attempt on 6/8/26 at 1:44 p.m. Resident #1 had a red substance streaked around her mouth and down her chin and neck. Resident #1 kept mumbling and asking for help while being interviewed and observed. A staff member was informed that Resident #1 needed assistance and observed staff enter Resident #1's room to help her. During an observation on 6/8/26 at 2:42 p.m. Resident #1 was lying in bed, sleeping, and covered with blanket. Resident #1 had a red colored substance around her mouth and streaked down her chin and neck. During an interview on 6/9/26 at 1:33 p.m. CNA A said she was working the 100 Hall on 6/8/26 and she and CNA B had laid Resident #1 down yesterday after they were told Resident #1 was asking for help. CNA A said Resident #1 did not have anything on her mouth, face, or neck when they laid her down. CNA A said she remembered them wiping down Resident #1. CNA A said the importance of ensuring residents were cleaned up after spilling something on themselves or down their chin and neck was for personal hygiene. During an interview on 6/10/26 at 2:14 p.m. the ADON said she expected staff to clean a resident's mouth, chin, and neck when needed. The ADON said a resident should be cleaned up prior to being laid down. The ADON ensuring a resident's mouth, neck, and chin were clean was so they did not feel dirty. Record review of the facility's Activities of Daily Living (ADL), Supporting policy revised 2/2025 indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 9 (Resident #3) residents reviewed for accident hazards. The facility failed to ensure CNA D and CNA E used a gait belt (an assistive device used by caregivers and physical therapists to help patients safely stand, walk, or transfer between chairs and beds) when transferring Resident #3 from the wheelchair to the bed on [DATE]. The failure could place dependent residents at risk for falls, significant injuries and decreased quality of life.Findings Include: Record review of the face sheet dated [DATE] indicated Resident #3 was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Myasthenia Gravis (a condition that causes weakness in the voluntary muscles), lack of coordination, cognitive communication deficit (an impairment in communication), and weakness. Record review of the MDS dated [DATE] indicated Resident #3 sometimes understood others and was usually understood by others. The MDS indicated Resident #3 did not have a BIMS score. The MDS indicated Resident #3 was dependent on staff for transfers. Record review of the care plan revised [DATE] indicated Resident #3 had an ADL self-care performance deficit related to confusion, fatigue, impaired balance, and limited mobility. Record review of a progress note dated [DATE] indicated Resident #3 expired in the facility. Record review of video footage from electronic monitoring indicated on [DATE] at 5:59 pm 2 CNAs transferred Resident #3 from the wheelchair to the bed without a gait belt. The video footage indicated the CNAs lifted Resident #3 out of the wheelchair from under both arms and by the back of his pants and put him in bed. During an interview on [DATE] at 12:52 p.m. CNA E said she had worked the night shift on [DATE]. CNA E said Resident #3 was already in bed when she started her shift on [DATE]. During an interview on [DATE] at 1:33. CNA D said she had worked the night shift on [DATE]. CNA E said Resident #3 was already in bed when she started her shift on [DATE]. During an interview on [DATE] at 3:13 p.m. the DON identified CNA D and CNA E as the CNAs in the video dated [DATE]. During an interview on [DATE] at 9:52 a.m. CNA E said she was unable to come to the facility to review the video dated [DATE]. During an interview on [DATE] at 10:05 a.m. CNA D said she was one of the CNAs in the video dated [DATE]. CNA E said they did not properly transfer Resident #3 on the video dated [DATE]. CNA E said they did not use a gait belt or mechanical lift and instead lifted Resident #3 from under the arms and by the back of his pants. CNA E said the importance of not transferring a resident by lifting them from underneath their arms was because they might have a pacemaker in place and that using a gait belt was the proper way to transfer a resident. During an interview on [DATE] at 10:25 a.m. PTA F reviewed the video dated [DATE] regarding transfer of Resident #3. PTA F said the CNAs improperly transferred Resident #3 by not using a gait belt, lifting under his arms, and pulling up on the back of his pants. PTA F said the importance of proper transfers was to prevent injuring the residents. PTA F said lifting a resident from under the arms when transferring could cause damage to the nerves, tendons, and/or ligaments in the shoulder. PTA F said pulling up on the back of a resident's pants was unstable as the pants could slip or tear causing the resident to trip and possibly injuring themselves. During an interview on [DATE] at 2:14 p.m. the ADON said she expected staff to use a gait belt when transferring a resident from the wheelchair to the bed. The AODN said it was not acceptable for a resident to be transferred by lifting them up from under their arms and by the back of their pants. The ADON said the importance of proper transfers was to prevent injuring the residents. Record review of the facility's Safe Lifting and Movement of Residents policy revised 7/2017 indicated, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving residents. 2. Manual lifting of residents shall be eliminated when feasible.4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral board (an assistive device designed to help caregivers smoothly move immobile patients between to horizontal surfaces)) and mechanical lifting devices.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (ADON) and 1 of 5 (Resident #2) residents viewed for infection control. The facility failed to ensure the ADON performed hand hygiene between glove changes while providing wound care to Resident #2 on 6/9/26. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building.Findings Include: During an observation and interview on 6/9/26 at 10:18 a.m. revealed the ADON performed wound care on Resident #2 with assistance from CNA C. The ADON gathered supplies from the treatment cart including bottle of Dakins solution (a mild, diluted bleach antiseptic used to clean acute and chronic wounds, prevent infections, and reduce odor) from bottom drawer of cart and placed on bedside table covered with wax paper. The ADON entered the room, performed hand hygiene and put on a gown and gloves. CNA C assisted in turning Resident #2 onto her side and holding Resident #2 in place. The ADON removed the dressing dated 6/9/26 and gauze that was in the wound bed. The ADON said wound care had been performed on the night shift due to Resident #2 having a bowel movement and the dressing getting dirty. The ADON removed her gloves, did not perform hand hygiene, and put on sterile gloves. The ADON picked up the non-sterile bottle of Dakins solution and wet gauze. The ADON cleansed the wound and packed the wound with Dakins soaked gauze. The ADON applied silicone faced foam and a border dressing (an advanced, multi-layer bandage that featured soft, atraumatic silicone contact layer that adheres to only the surrounding skin and a highly absorbent foam pad) to the wound. The ADON removed her gloves, did not perform hand hygiene, and began digging in her pockets for a marker. The ADON washed her hands, obtained a marker from her pocket, picked up trash from the floor, washed her hands, put on gloves, and dated and initialed the dressing. The ADON gathered supplies and exited the room. During an interview on 6/9/26 at 12:42 p.m. the ADON said hand hygiene should be performed before starting wound care and between glove changes. The ADON said she chose to use sterile gloves when performing wound care and going from wet to dry, but that the sterile gloves were not required. The ADON said she did not perform hand hygiene when she took off her gloves after cleaning Resident #2's wound because she had accidentally thrown away her hand sanitizer. The ADON said the importance of proper hand hygiene was to prevent infections. During an interview on 6/9/26 at 3:13 p.m. the DON said she expected staff to perform hand hygiene before and after entering a resident room or providing care and between glove changes. The DON said the importance of proper hand hygiene was infection control. Record review of the facility's Handwashing/Hand Hygiene policy revised 1/2025 indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. immediately before touching a resident.c. after contact with blood, body fluids, or contaminated surfaces.g. immediately after glove removal.

Based on observation, interview, and record review, the facility failed to ensure food items were properly stored, prepared, distributed, and dated under sanitary conditions for 1 of 1 facility kitchens. The facility failed to ensure: *Eight cups containing a pudding-like substance were labeled or dated.*One container for pureed liquids was covered, dated, and labeled.*Four bowls of salads were labeled or dated.*Six cups of orange liquid were dated or labeled.*Three milk-like substances containers were dated or labeled.*Four cups of red liquid were dated or labeled.*One two-gallon pitchers, one with brown tea like liquid, and one with red liquid were dated or labeled.*The flour bin and cornmeal bulk bin did not have food storage bowl inside of the product bins.*An opened box of pinto beans was reclosed and sealed. 2.The facility failed to ensure the temperature log for the hot food line was maintained, the temperature log was not available for review at the time of the investigation. These failures could place residents who ate food for the kitchen at risk of foodborne illness. Finding included: During observations on 4/22/2026 in the kitchen the following was noted: *At 11:10 A.M., in the refrigerator were eight cups covered, with pudding-like substances that were not labeled or dated*At 11:11 A.M., one container of pureed liquids not covered, dated, or labeled.*At 11:12 A.M., four bowls of salad covered, however not labeled or dated. *At 11:14 A.M., six cups of orange liquid not dated or labeled. *At 11:15 A.M., three milk-like substances covered, however not dated or labeled. *At 11:16 A.M., four cups of red liquid covered, however not dated or labeled. *At 11:17 A.M., two one-gallon pitchers, one with brown tea like liquid and one with red liquid not dated or labeled.*At 11:18 A.M., large metal pan covered with tinfoil containing several smaller items wrapped in tinfoil (Dietary Manager said were sweet potatoes) not dated or labeled.*At 11:19 A.M., In the dry food storage area, bowls were observed inside the flour and cornmeal bins being used as scoops. *At 11:20 A.M., Dry pinto beans in a box not resealed after open box dated 4/7/2026 *At 11: 21 A.M., the time of the investigation, no temperature logs for the hot food line were available for review. Durning observations and interview on 04/22/2026 at 11:22A.M., the dietary aide stated that while cooking chicken strips, the grease temperature was checked and measured at 165*F. She said that staff typically check food temperatures prior to service; however, she acknowledged that temperatures are not consistently documented. The aide said that although logs are not always completed, staff do routinely check food temperatures to ensure menu food items meet required regulatory standards prior to serving. Durning observations and interview on 04/22/2026 at 11:39A.M., the Dietary Manager said that food temperature logs are not consistently maintained at this time. Dietary Manager reported that the previous dietary manager discarded or removed many of the existing temperature logs and records. She indicated that although she currently checked temperatures of each dish on the menu, she was unable to provide documentation for investigation review due to the process of developing new logs records. She stated she was training new staff in proper food storage and temperature control, including maintaining hot foods on the steam table at (greater or equal) to 135*F and cold foods at (less than or equal) to 41*F. The Dietary Manager stated she had been in her role for approximately three weeks and was currently in process of training new kitchen staff and had initiated a plan to develop and maintain temperature logs moving forward. Durning observations and interview on 4/22/2026 at 3:54 PM., the Dietary Manager, and kitchen staff prepared the steam table for dinner service. The Dietary Manager tested items included beef stroganoff (158*F), mechanical beef stroganoff (178*F), diced carrots (172*F), broccoli Cheese (162*F), tomatoes soup (174*F), pureed stroganoff (150*F), pureed potatoes (180*F), pureed carrots (162*F). All food temperatures was within acceptable range. Durning an interview on 4/23/2026 at 10:30 AM., the Administrator, said improvement with the New Dietary Manager within the last three weeks had been reported from the Resident's Councils and the facility residents. The Administrator reported implementation of temperature logs were in progress. He stated he was assisting the Dietary Manager with revising and revamping the temperature log. The Administrator provided certification documentation for the Dietary Manager. The Administrator further stated that in-services were being conducted for dietary staff on food storage, temperature monitoring and documentation, and proper cleaning and sanitary storage of dishes and utensils. 4/23/2026 Reviewed The Texas Food Establishment Rules, dated February 2021 indicated: .3-305.11 Food StorageFood shall be protected from contamination by storing the food:(1) In a clean, dry location.(2) Where it is not exposed to slash, dust or other contamination .4/23/2026 Reviewed the Facility Food and Nutrition Services dated February 2021 Policy indicated: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 3. Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled mealtime, and in accordance with the resident's medication requirements.4/23/2026 Reviewed the Facility Food Preparation and Service dated February 2021 Policy indicated:Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices .4 Food Distribution means the processes involved in getting food to the residents. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions 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 then delivered to residents' rooms or dining areas to be distributed, covering food is appropriate, either individually or in a mobile food cart.4/23/2026 Reviewed the Facility Food Distribution and Service dated February 2021 Policy indicated: .1. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held m the temperature danger zone are discarded after 4 hours 2. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.4/23/2026 Reviewed the FDA Food Code (Section 3-501.16), Time/Temperature Control for Safety (TCS) foods must be maintained at a hot holding temperature of 135*f (57*C) or higher. A hot food temperature log should record these temperatures frequently- typically every 2-4 hours to ensure safety, verify equipment function, and show regulatory Compliance.04/23/2026 Reviewed the FDA Food Code (Section 3-501.17), Refrigerated shall be clearly marked, at the time the original container is opened in a food establishment and if held for more than 24 hours, to indicate the date or day by which the food shall be consumed or discarded.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 facility kitchens.The facility failed to ensure: - there was soap in the dispenser at the handwash sink by the pantry door and in the dispenser in the bathroom.- a foot operated pedal trash can for each of the handwash sinks.- the sugar bulk bin did not have a scoop inside of product. - the microwave was kept clean.- the reach-in stainless steel freezers and coolers were free from food debris, dried liquid splatters and fingerprints.- thickened liquid products were dated when opened.- an opened box of a frozen food product was reclosed and sealed.- thawing hamburger meat was placed in a container or on a tray to catch meat juices.-a prepared pan of fruit gelatin was labeled and dated. - the drip pan area under the burners on the stove was kept clean.- the deep fryer was kept clean.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included:During observations and interviews on 02/08/2026 of the kitchen the following was noted:*at 10:20 AM the handwash sink by the pantry door had no hand soap in the dispenser. [NAME] B, said at that time, they did not have any for that sink and to use the other sink by the back door. There was no foot-operated trash cans at handwash sinks. Employees had to use 55-gallon trash cans and remove the lid with their clean hands. *at 10:40 AM the employee restroom in the kitchen had no soap in the dispenser. *at 10:47 AM the bulk sugar bin in the pantry had a plastic bowl being used as a scoop left inside the product. *at 10:49 AM the microwave by the kitchen door was heavily soiled with food debris, splatters and spills on the rotating platter and on the walls and the door. *at 10:51 AM the 2 door stainless steel cooler labeled Milk: the bottom shelves had dried spills and splatters. The door sills had wet and dried liquid splatters. There was one 46 oz Nectar Thick Apple juice that had no open date, and one 46 oz. Nectar Thick Orange juice that had no open date. The packaging indicated After opening, may be kept up to 7 days under refrigeration. There was one serving tray with 7-4 oz glasses of orange juice and 3-6 oz glasses of milk had no label or date it was prepared. *at 10:55 AM the 2 door stainless steel freezer labeled Meats: There was one 10 lb. box of Chickenless Tenders Soy Protein Tender Shaped pieces that had the plastic bag opened and not re-sealed. The door sills and lower shelves were soiled with food debris. There were fingerprints on the door handles made with a white dusty substance. *at 10:58 AM the 2 door stainless steel freezer labeled Veggies: had dried liquid drips on the door sills and vents. *at 10:59 AM the 2 door stainless steel freezer (last one on right): had food debris on the door sills in the hinge areas of doors. *at 11:00 AM the 2 door stainless steel cooler (last one on left): there was one-5 pound chub of hamburger meat thawing on top of a cardboard container. There was food debris and dried spills in the cooler gaskets and in the hinge areas of the doors. *at 11:02 AM the 2 door stainless steel cooler (middle on left): there was one half-size 6 deep stainless steel pan that was partially covered with plastic wrap and had an unknown food item inside. There was no label or date on the container. [NAME] B said the container held fruit gelatin. *at 11:05 AM the 2 door stainless steel cooler (first on left): there was food debris and dried liquid splatters on the bottom shelves, door sills, and vents. *at 11:10 AM the Drip pan under the stove burners was caked with thick, black substances and burned food debris, liquids, and a paper clip. *at 11:12 AM [NAME] B said fresh oil was placed in the deep fryer the preceding Tuesday (02/03/2026) because they always have it fresh for fish on Friday. She said nothing had been fried since Friday. The oil in the fryer was dark in appearance and had fried bits of cornmeal floating on the surface. There were four French fries lying on the drain ledge of the fryer. The back area of fryer was caked with thick golden brown and dark brown built up oil. During observations and interviews on 02/09/2026 of the kitchen the following was noted: *at 11:08 AM the employee restroom in the kitchen had no soap in the dispenser. *at 11:35 AM beverage containers were being placed in the ice bin beside the steam table. one 46 oz Nectar Thick Orange Juice had no open date; two 46 oz Nectar Thick apple juice had no open dates; one 46 oz honey thick sweet tea had no open date. DA C said she did not know the thickened liquids had an expiration date. She said they were to date items when they are opened.*at 11:20 AM the DM asked if there had been concerns from the previous day's kitchen tour and she was told what was deficient. She had no comment regarding the findings. *at 11:40 AM there were 5 individual bowls of chili and 5 individual bowls of squash set down in the dry heated steam table well. The DM said they had 5 people on pureed diets so they just prepared the puree and placed it in the individual bowls on the steam table. The DM placed a zippered bag of pureed bread she had gotten from the cooler on the steam table line. She placed a 2 oz scoop beside the bag of bread for serving. *At 12:10 PM tray line service began with 2 cooks serving side by side. [NAME] D was serving the potatoes, and pureed items that were on his end of the steam table. He did not open the bag of pureed bread and serve the pureed bread at any time during service. The dining room was served at 12:25 PM and service continued with 12:29 PM hall 200 cart; 12:35 PM hall 100 cart; 12:44 PM hall 400 cart; and 12:55 PM hall 300 cart. Hall 300 cart left kitchen at 12:55 PM. Pureed bread was not served to any residents receiving pureed food.During an interview on 02/09/2026 the DM rolled her eyes and had no comment when told the residents did not receive their portion of pureed bread. Review of the facility policy titled Sanitation, revised November 2022, indicated .1. All kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.Review of the facility policy titled Food Safety and Sanitation, dated 2023, indicated .d. Employees will wash their hands just before they start work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes; and touching face, hair, other people or surfaces or items with potential for contamination.The Texas Food Establishment Rules, dated October 2015, revealed:S228.68. Preventing Contamination From Equipment, Utensils, and Linens. (a) Food shall only contact surfaces of: (1) equipment and utensils that are cleaned as specified under SS228.113, 228.114 and 228.115 of this title and sanitized as specified under SS228.116, 228.117 and 228.118 of this title; . S228.114. Frequency of Cleaning.(c) Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues Food and Drug Administration Code, Dated, 2013, indicated the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B)The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations 3-305.11 Food StorageFood shall be protected from contamination by storing the food:(1) In a clean, dry location;(2) Where it is not exposed to slash, dust or other contamination .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meals (lunch meal) reviewed for menus and nutritional adequacy. Dietary staff did not serve pureed bread during the noon meal on 02/09/26 to any residents eating pureed food provided by the dietary department.This failure could place residents who eat food from the kitchen at risk of not having their nutritional needs met. Findings included: The planned menu dated 02/09/2026 for the noon meal was beef chili, boiled squash, scalloped potatoes, cornbread, and cake with frosting.The diet spreadsheet for the noon meal indicated residents on pureed diets were to receive pureed bread 2 ounce. (#16 dip).During an observation and interview in the dietary department on 02/09/2026 at 11:45 AM the DM retrieved a zipped plastic bag from the cooler that was labeled as pureed bread. She placed it on the serving line and placed a #16 dipper on top of the bag. She said the bread was not cornbread but regular bread.During an observation on 02/09/026 at 12:10 PM, tray line service began and continued until 12:55 PM. The dietary trays containing pureed food items did not have pureed bread placed on the plates or in a dish on the trays. The DM was not present at the serving line during the entire meal service.During an interview on 02/09/2026 at 01:05 PM, the DM said it was the cook's responsibility to place the pureed bread on the dietary trays. She said she expected bread to be served to all residents if it was part of the menu.Review of a facility Diet Roster dated 02/10/2026 indicated there were 4 residents receiving pureed food from the kitchen.Review of a facility policy titles Menu Checklist: Nutritional and Regulatory Requirements dated 2023 indicated .Grains: Minimum of 6 ounce equivalents per day (including evening snack(. Includes breads, grains, cereals. 1 Grain is a 1 ounce equivalent: includes 1 slice of bread, 1 small dinner roll,.

Based on interview and record review, the facility failed to ensure MDS data was electronically transmitted to the CMS System within 14 days after completion of the assessment for 1 of 1 resident reviewed for assessments. (Resident #77) The facility did not transmit an admission MDS assessment within 14 days into the CMS system as required after Resident #77 was admitted . This failure could place residents at risk of having an incomplete record.Findings included: Record review of Resident #77's face sheet indicated she was a re-admission dated 9/20/2025.A record review of the most recent MDS assessment for Resident #77 was dated 09/21/2025.During an interview on 02/10/2026 at 10:30 AM, the MDS Coordinator said Resident #77 was admitted on [DATE] and it was an oversight that this resident's submission was missed. She said they have a new software program that is set to catch any further oversights, and MDS should have been transmitted on 10/4/2025. She said, that the facility does not have its own policy, therefore the policy they use is CMS's RAI Assessment Transmission policy that refers to the electric transmission by state and federal guidelines.

Based on observation and interview, the facility failed to display information on how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by such benefits for 1 of 1 facility bulletin. The facility failed to post the appropriate information in a location accessible to residents and their representatives. This failure could place residents at risk of delayed access to entitled benefits, interruption of services, and impaired ability to exercise informed decision-making regarding payment and coverage for their care. The findings include: During an observation on 02/09/2026 at 3:15 PM of the facility's required postings bulletin board, the information for how to apply for and use Medicare and Medicaid benefits was not displayed. During an interview on 02/09/2026 at 3:29 PM, the SW indicated that he was unsure where this required posting was located or if it was posted. During an interview on 02/09/2026 at 3:31 PM, the DON indicated that she was unsure where this required posting was located or if it was posted. During an interview on 02/09/2026 at 3:33 PM, the ADM indicated that the information might be located in the admissions office, but that he did not have this required posting made available to residents. The ADM indicated that the risk to residents for not having the appropriate required postings available to residents could include a lack of knowledge and information sharing that might assist them in certain situations. During an interview on 02/09/2026 at 3:42 PM, the Admissions Director indicated that there is nothing posted within the facility regarding how to apply for and use Medicare and Medicaid benefits, but that she is available to help the residents should they need it. During an interview on 02/10/2026 at 10:50 AM the ADM indicated that there was no specific facility policy on required postings and that the facility follows Health and Human Services and Centers for Medicare and Medicaid Services guidelines.

Based on observation and interview, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent state agencies and advocacy groups in a form and manner accessible and understandable to residents and resident representatives for 1 of 1 facility bulletin. The facility failed to post the contact information for the Medicaid Fraud Control Unit in an accessible location. This failure could place residents at risk of not having access to the appropriate agency to report instances of fraud by a Medicaid provider. The findings include: During an observation on 02/09/2026 at 3:15 PM of the facility's required postings bulletin board, the information for the Medicaid Fraud Control Unit was not displayed. During an interview on 02/09/2026 at 3:29 PM, the SW indicated that he was unsure where this required posting was located or if it was posted. During an interview on 02/09/2026 at 3:31 PM, the DON indicated that she was unsure where this required posting was located or if it was posted. During an interview on 02/09/2026 at 3:33 PM, the ADM indicated that he did not have this required posting made available to residents. The ADM indicated that the risk to residents for not having the appropriate required postings available to residents could include a lack of knowledge and information sharing that might assist them in certain situations. During an interview on 02/10/2026 at 10:50 AM the ADM indicated that there was no specific facility policy on required postings and that the facility follows Health and Human Services and Centers for Medicare and Medicaid Services guidelines.

Based on interview and record review, the facility failed to ensure residents were provided reasonable access to receive their mail in a timely manner for 1 of 9 confidential residents (Confidential Resident #1) reviewed. The facility failed to implement a system to distribute incoming mail daily. This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials. The findings include: During a confidential group interview at an undisclosed date and time, 1 of 9 confidential residents confirmed that they had recently been expecting a package on a Saturday and it was not received until the following Monday. An interview on 02/09/2026 at 1:05 PM with Receptionist A indicated that mail was delivered to a Post Office Box in town, obtained throughout the week, and was distributed directly to residents. Receptionist A indicated that she was unsure if mail was obtained on Saturdays. An interview on 02/10/2026 at 11:01 AM with the ADM, Human Resources manager, and Business Office manager indicated that there was no process for obtaining and distributing mail from the Post Office Box to the residents on Saturdays. The ADM indicated that the key to the Post Office Box had not been made available to the weekend receptionist. The ADM indicated that the risk to residents could include an inability to keep in touch with friends or relatives. Record review of a policy dated February 2021 titled Resident Rights indicated the following: Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' rights to:.f. communication with and access to people and services, both inside and outside the facility;.cc. access to a telephone, mail, and email;dd. communicate in person and by mail, email, and telephone with privacy.

Based on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report was turned into the state survey agency (HHSC) within 5 working days of the reported incident for Resident #1. This failure could place residents at risk for abuse and neglect. Findings included:Record review of Resident #1's face sheet, dated 01/08/26, reflected he was an [AGE] year-old male, admitted on [DATE]. His diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and myelopathy (a spinal cord injury from severe compression, often due to aging, herniated discs, or trauma). Record review of Resident #1's quarterly MDS assessment, dated 12/08/25, reflected he had a BIMS score of 08, which indicated moderate cognitive impairment. Record review of the facility's provider investigation report for Resident #1, dated 12/23/25, reflected Resident #1's family reported concerns during a care plan meeting to staff related to inaccuracy of timing of documentation of Resident #1's fall that occurred on 12/18/25. The facility addressed the family's concerns and were satisfied with the outcome of the care plan meeting. Ultimately, the facility's investigation concluded the allegation was inconclusive. The allegation was reported to the state survey agency on 12/21/25. Record review of the TULIP website, accessed on 01/08/25 at 2:19 PM, reflected on the page for intake # 1058073 that a 5-day report or provider investigation report had not been turned into the state survey agency. During an interview on 01/08/26 at 11:31 AM, the Administrator said as far as he knew he did not send in the 5-day investigation report for the incident regarding Resident #1. He said he was not sure what happened. He said there may have been an internet outage, but he was not sure. He said there was no risk to the residents because the report was not turned into the state. He said the interventions were put into place, but the report had not been turned into the state survey agency. Record review of the facility's policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised September 2022, reflected: .Follow-up Report1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report .

Based on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 3 of 11 residents (Resident #1, #2 and #3) reviewed for ADL care in that: The facility failed to ensure Resident #1 was provided appropriate incontinent care on 12/9/25 at 2:00 p.m. when she was observed wearing two briefs (double briefed) at the same time.The facility failed to ensure Resident #2 and Resident #3 was provided appropriate incontinent care at an unknown date and time when they said they had been double briefed in the facility.This failure could place all residents at risk of loss of dignity, skin breakdown, infection, and hospitalization.Findings included: Resident #2 Review of an admission Record dated 12/9/25 for Resident #2 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of chronic respiratory failure, chronic heart failure, type 2 diabetes, abnormal gait and mobility, and generalized weakness. Record review of an annual assessment MDS dated [DATE] indicated Resident #2 had moderately impaired cognition with a BIMS of 8. She required setup/cleanup assistance with eating and oral hygiene; she required maximal assist upper body dressing; she required total assist for toileting hygiene, shower/bath, lower body dressing, and putting on/taking off footwear. Record review of a comprehensive care plan dated 5/25/24 indicated Resident #2 had bowel and bladder incontinence related to diagnosis of immobility and obesity. Appropriate interventions was in place including check resident as required for incontinence and change disposable brief as needed. During an interview on 12/9/25 at 10:15 a.m., Resident #2 said staff had double briefed her as often as they can get away with. Resident #2 said she could not recall any specific dates or staff members involved. During an observation on 12/9/25 at 11:00 a.m., Resident #2 was assisted with incontinent care by CNA C. Resident #2 was not double-briefed and no concerns of skin integrity were noted. Review of a skin assessment dated [DATE] indicated Resident #2 had no alterations in skin integrity noted. Resident #3 Review of an admission Record dated 12/9/25 for Resident #3 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of functional quadriplegia (inability to move), type 2 diabetes, and morbid obesity.Record review of a quarterly MDS dated [DATE] indicated Resident #3 had intact cognition with a BIMS of 15. She required setup/cleanup assistance with eating; she required supervision for oral hygiene; she required moderate assist for personal hygiene; she required maximal assistance for upper body dressing; she was dependent on staff for toileting hygiene, shower/bath, lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder.Record review of a comprehensive care plan dated 12/3/25 indicated Resident #3 was at risk for UTIs and skin breakdown related to bladder and bowel incontinence. Appropriate interventions was in place including monitor every 2 hours and change brief promptly for incontinent episodes. During an interview on 12/9/25 at 1:10 p.m., Resident #3 said facility staff had put two briefs on her in the past. Resident #3 said she could not recall specific details of when it happened or what staff members were involved. Resident #3 said she was not double briefed right now. Review of a skin assessment dated [DATE] indicated Resident #3 had rash to her groin with no other alterations in skin integrity.Resident #1Review of an admission Record dated 12/9/25 for Resident #1 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of Unspecified Dementia (altered cognition), cognitive communication deficit (impaired ability to communicate), and age-related physical debility. Record review of an annual assessment MDS dated [DATE] indicated Resident #1 had severely impaired cognition with a BIMS of 5. She required setup/cleanup assistance with eating; she required moderate assistance with oral hygiene, upper body dressing, and personal hygiene; she required maximal assistance with toileting hygiene, shower/bath, lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder.Record review of a comprehensive care plan dated 2/3/25 indicated Resident #1 had bowel and bladder incontinence related to diagnosis of dementia. Appropriate interventions were in place including check resident as required for incontinence and change disposable brief as needed. Record review of a comprehensive care plan dated 7/19/25 indicated Resident #1 had a history of UTIs. Appropriate interventions was in place including check every 2 hours for incontinence, and wash, rinse, and dry soiled areas.During an observation on 12/9/25 at 2:00 p.m., CNA A and CNA B assisted Resident #1 with incontinent care. Resident #1 was observed to be wearing two briefs, both saturated with urine. There was redness noted to her buttocks, barrier cream was applied by CNAs.During an interview on 12/9/25 at 2:15 p.m., CNA A said she had seen other residents wearing two briefs in the past, but not recently. CNA A could not recall resident names who had been seen wearing two incontinent briefs. CNA A said using two briefs (double briefing) on a resident was not acceptable practice because it could cause skin breakdown.During an interview on 12/9/25 at 2:18 p.m., CNA B said she had not seen any other residents in the facility wearing two briefs. CNA B said double briefing was not allowed as it could cause skin breakdown.During an interview on 12/9/25 at 2:30 p.m., CNA C said he was assigned Resident #1's care that day. CNA C said he checked on Resident #1 at approximately 6:00 a.m. and again when he got her up for lunch approximately 11:00 a.m., and Resident #1's brief was dry. CNA C said he did not notice Resident #1 was double briefed. CNA C said double briefing was not permitted in the facility because it could cause skin breakdown.During an interview on 12/9/25 at 2:35 p.m., LVN D said she had not observed any resident in the facility being double briefed. LVN D said it was unacceptable practice to double brief a resident and she would immediately address it with the assigned staff member if she observed a resident double briefed. LVN D said double briefing can cause skin integrity issues and infection.During a telephone interview on 12/9/25 at 3:20 p.m., CNA E said she worked 6:00 p.m. to 6:00 a.m. on 12/8/25 and was assigned to care for Resident #1. CNA E said she double briefed Resident #1 because other staff members told her to. CNA E said she could not recall the staff member who told her to double brief Resident #1. CNA E said she had completed incontinent care training and skills check offs as part of her new hire training which indicated not to double brief residents. During an interview on 12/11/25 at 5:10 p.m., the DON said double briefing was not an accepted practice. The DON said she had already begun disciplinary action with CNA E and CNA D and planned to in-service staff on appropriate incontinent care. The DON said risks of double briefing include skin breakdown and infection.During an interview on 12/11/25 at 5:20 p.m., the ADM said he was responsible for ensuring all staff receive required training from the time they are hired. The ADM said he was unsure if the facility had a specific policy that addressed double briefing, but the practice was not allowed. The ADM said he planned on in-servicing staff regarding appropriate incontinent care.Review of a Competency Assessment Perineal Care dated 12/2/25 indicated CNA E demonstrated competency in all required skills. Review of a facility policy titled Perineal Care dated February 2018 indicated .The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review of a facility policy titled Activities of Daily Living (ADL), Supporting dated February 2025 indicated .Residents who are unable to carry out activities of daily living will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to protect the residents' right to be free from physical abuse and neglect for 2 of 11 residents (Resident #4 and #5) reviewed for abuse, neglect, and exploitation in that: The facility failed to ensure Resident #4 was free from physical abuse on 10/6/25 at approximately 6:00 a.m. when CNA F grabbed her by the arm causing a skin tear. The facility failed to ensure Resident #5 was free from neglect on 5/14/25 when CNA G left her unattended in the shower. Resident #5 did not suffer an injury. These failures could place all residents at risk of loss of dignity, injury, and hospitalization.Findings included: Resident #4 Review of an admission Record dated 12/11/25 for Resident #4 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of history of transient ischemic attack (stroke), cognitive communication deficit (impaired communication), muscle wasting and atrophy, and COPD (chronic obstructive pulmonary disease).Record review of a quarterly MDS dated [DATE] indicated Resident #4 had severely impaired cognition with a BIMS of 7. She required moderate assistance with eating, upper body dressing, and personal hygiene; she required maximal assistance with oral hygiene, toileting hygiene, shower/bath, lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder.Record review of a comprehensive care plan dated 6/8/25 indicated Resident #4 had an ADL self-care performance deficit related to fatigue, impaired balance, limited mobility, limited range of motion, and musculoskeletal impairment. Appropriate interventions were in place including limited/moderate assistance with dressing. Resident #6Review of an admission Record dated 12/11/25 for Resident #6 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of mild cognitive impairment of uncertain or unknown etiology (impaired cognition unknown cause), cognitive communication deficit (difficulty communicating), and encephalopathy (altered mental state).Record review of a comprehensive care plan dated 6/26/24 indicated Resident #6 had potential for impaired thought processes related to mild cognitive impairment. Appropriate interventions were in place including maintaining consistent routine, monitoring for changes in cognition, and providing consistent caregivers as much as possible to decrease confusion.Review of Resident #4's nursing progress note by RN J dated 10/6/25 at 9:06 a.m. indicated .At approximately 0520, the staff aid rolled the resident into the dining area to wait for breakfast. The resident sat there for about 10 minutes, and nurse rolled resident back to her room because she was bleeding under her left arm sleeve. Skin tear located on superior side of left forearm. Nurse cleaned with saline water and dressed in strips and bandage. Resident stated that the incident happened by agency aid being too rough with her.Review of an incident report dated 10/6/25 at 5:30 a.m. indicated Resident #4 sustained a skin tear in her room. Resident #4's description of the event indicated I was telling her to stop and she was being too rough. A note in the same incident report indicated Resident was clearly able to state what happened to her.Review of a skin assessment dated [DATE] at 5:55 a.m., completed by RN J indicated Resident #4 had a skin tear on her left antecubital (inner part of elbow). During an interview on 12/9/25 at 10:55 a.m., Resident #4 said she could not recall the incident and did not want to speak to surveyor.Review of a written statement regarding incident involving Resident #4 by RN J dated 10/6/25 indicated .Nurse walked over to help the resident and noticed large circle of blood on the resident's shirt on her left forearm. Nurse asked resident what happened and resident stated that girl was being too rough with me, I told her to stop!.Once in room, nurse provided privacy and resident in B bed was crying about her own experience with aide. Resident B told nurse that aide had been too rough with resident in Bed A. Bed B also said that Bed A told the aide that she was bleeding prior to her shirt being put on. Bed B said that she heard her saying stop, you're being too rough, you're hurting me, you cut me. Resident in Bed B said that aide continued to dress the resident and she didn't heard her say anything.During an interview on 12/10/25 at 11:45 a.m., Resident #6, who was Resident #4's roommate, said she could not recall any incident of alleged abuse. Resident #6 said she had not been abused or mistreated in the facility.Review of a skin assessment dated [DATE] at 11:25 a.m. indicated Resident #6 had edema to bilateral lower extremities but no other alterations in skin integrity and no complaints of pain.Review of a phone interview on 10/6/25 at 8:40 a.m. conducted by ADM with CNA F regarding incident with Resident #4 indicated .When asked about the incident she responded that she went in to assist resident with morning ADL care to get her ready for breakfast. During transfer she reported resident was leaning forward, grabbing at her bed and wheelchair. During this process a skin tear to residents left arm happened .Attempted telephone interviews with CNA F on 12/11/25 at 4:15 p.m. and 5:25 p.m. Requested personnel file for CNA F from ADM and was advised by ADM the facility had no file for CNA because she was an agency employee.Review of a facility policy titled Safe Lifting and Movement of Residents indicated .In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.2.Review of an admission Record dated 12/10/25 for Resident #5 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of Unspecified Dementia (altered cognition), cognitive communication deficit (impaired ability to communicate), difficulty walking, unsteadiness on feet, and muscle wasting and atrophy.Record review of a quarterly MDS dated [DATE] indicated Resident #5 had moderately impaired cognition with a BIMS of 8. She required setup/cleanup assistance with eating; she required supervision with oral hygiene; she required moderate assistance for upper body dressing and personal hygiene; she required maximal assistance for toileting hygiene, shower/bath, lower body dressing, and putting on/taking off footwear.Record review of a comprehensive care plan dated 10/19/25 indicated Resident #5 had limited mobility related to obesity, thrombocytopenia, pain, and generalized weakness requiring a wheelchair for mobility. Appropriate interventions were in place for ADL assistance which included extensive staff assistance with bathing.Record review of a comprehensive care plan dated 10/19/24 indicated Resident #5 insisted on transferring herself to/from bed/chair/toilet, she was reminded by staff frequently to call for assistance. During an interview on 12/10/25 at 12:30 p.m., Resident #5 said a CNA left her in the shower, but she was unable to provide additional details. Resident #5 said she could not recall the incident well.During an interview on 12/10/25 at 1:00 p.m., LVN H said she worked 6:00 a.m. to 6:00 p.m. on 5/14/25 and observed CNA G sitting in the hallway in a chair on her cell phone while Resident #5's call light was active. LVN H said she told CNA G she needed to take care of the residents. LVN H said CNA G told her Resident #5 was being rude and she wasn't going to go back into her room. LVN H said she began answering call lights on the hall. LVN H said she noted CNA G was then sitting at the nurse's station on her cell phone. LVN H said she again told CNA G she needed to get off her phone and take care of the residents. LVN H said CNA G told her she would just go home, then. LVN H said CNA G left the facility and the CNAs working the other halls took care of her assigned residents the rest of the night. LVN H said she continued answering call lights and assisted Resident #5 out of the shower and into her chair.During an interview on 12/10/25 at 1:20 p.m., CNA G said she worked 6:00 p.m. to 6:00 a.m. on 5/14/25. CNA G said she was called into Resident #5's room and found her in the shower. CNA G said Resident #5 required assistance from two staff members for showering, but had put herself into the shower. CNA G said she left Resident #5 in the shower to go and get a towel for her to step out onto. CNA G said when she returned Resident #5 refused all care, hit her, and sprayed her with water. CNA G said she notified the charge nurse that Resident #5 refused care. CNA G said she left the facility that night with permission after notifying the scheduler. During an interview on 12/10/25 at 4:37 p.m., CNA H said she was the scheduler on 5/14/25. CNA H said that night CNA G left her shift early without notifying her for relief. CNA H said the other CNAs working had to cover CNA G's assigned hallway after she left early. During an interview on 12/11/25 at 5:10 p.m., the DON said residents who require shower assistance are never to be left alone during a shower. The DON said CNAs were expected to remain with the resident during a shower and utilize the call light to call for assistance if needed. The DON said nursing staff were expected to take care when assisting or transferring residents as many residents have thin skin. The DON said if a resident tells a staff member to stop or that they are hurting them, then they should stop immediately and get additional assistance. During an interview on 12/11/25 at 5:20 p.m., the ADM, who was the abuse coordinator, said CNAs were never to leave a resident alone in the shower if the resident required shower assistance. The ADM said CNAs were expected to utilize the emergency call lights if additional assistance is required. The ADM said CNAs were expected to assist residents with ADLs and/or transfers safely without causing harm to the residents. The ADM said he planned to conduct in-service training to address all concerns he was made aware of. The ADM said he conducted an investigation into the allegation of abuse related to Resident #4. The ADM said he interviewed CNA F and she said Resident #4 was attempting to lean over and grab her wheelchair which caused the skin tear. The ADM said Resident #4 had no history of physical aggression with staff members to his knowledge. The ADM said the facility did not have a file for CNA F because she was agency staff. The ADM said she was suspended immediately pending the investigation and placed on the do not use list going forward. Review of resident safe surveys conducted on 5/14/25 indicated 6 of 6 residents surveyed who were on CNA H's said they felt safe in the facility and were happy with their care.Review of facility policy titled Bath, Shower/Tub dated February 2018 indicated .Stay with resident throughout the bath. Never leave the resident unattended in the tub or shower.Review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 2021 indicated .Residents have the right to be free from abuse, neglect, misappropriation of property and exploitation.

Based on interviews and records review, the facility failed to provide adequate supervision for 1 of 3 residents (Resident #17) to prevent an avoidable accident.The facility failed to provide a timely response to the call light during change of shift for Resident #17 to prevent an avoidable accident. This resulted in Resident #17 having an actual fall on 08/09/2025, suffering a sprained left ankle injury.The failure could place residents at risk for accidents/ injury over which the facility had control, provided supervision, and assistive devices to each resident to prevent avoidable fall accidents. Finding included:Resident #17, named in the allegation, was not observed, or interviewed during the investigation. Discharge summary records revealed she was discharged on 08/19/2025 to an assisted living facility and was not available during the investigation. A review of Resident #17 face sheet dated [DATE] indicated she was a [AGE] year old female initially admitted on [DATE] with diagnoses of streptococcal infection, insomnia, sepsis unspecific, Parkinson's disease without dyskinesia (movement disorder), lichen sclerosus (condition that causes thin patches of the skin), pain in the left knee, trigger finger, age related osteoporosis, dysphagia (difficulty swallowing foods or liquids), ataxia (impaired balance or coordination), and cognitive communication deficit. A review of Resident #17's, quarterly MDS section C dated 08/5/2025, revealed a BIMS score of 10 (Brief Interview for Mental Status), indicated moderate cognitive impairment. A review of Resident # 17's care plan dated 07/28/2025, Transfers', indicated the resident required moderate assistance. Care Planned focus goals, indicated the resident was at risk for falls related to gait/balance problems, weakness, Parkinson's, difficulty ambulating. The resident was care planned for camera consented for surveillance to be on file. A review of Resident # 17 Nurse's Note dated 08/09/2025, revealed Fall Risk assessment indicated 1-2 falls in past 3 months. Recent hospitalization history in last 30 days, (Gait Balance problem while walking or unstable when making turns). Required use of assistive devices and balance problems while standing. A review of Resident #17's Provider Investigation Report dated 08/11/2025 indicated the resident had an unwitnessed fall dated 8/9/2025 at approximated 6:15AM to 6:30AM. The resident was found on floor near doorway in a slight leaning position, during morning shift change by CNA (C) and CNA (D). The provider investigation report indicated both CNA's immediately notified CN LVN (A), a full assessment was done, Resident #17# was able to answer questions, denied hitting her head, no bruises, or lacerations noted. A review of Resident #17's Provider Investigation Report dated 08/09/2025 at 11:00AM, the resident was transferred to hospital after complaining of left ankle soreness on standing. Hospital post x-ray resulted in sprained left ankle. Review of facility incident/accident reports for the past three (3) months revealed un-witnessed fall incidents report dated 08/03/2025 to 8/28/2025 during the 6PM to 6AM night shift, totaling 11 un-witnessed fall incidents throughout the facility, including hallway's 100, 300, and 400. During an interview on 10/27/2025 at 3:00PM, CNA (C) said, on 08/09/2025, she had arrived for 6AM shift and heard a resident in hallway 200 call for help, she immediately went down the hallway to Resident #17's room and sees the resident on the floor, a second aide arrived just seconds later. CNA (C) said, she immediately goes to get CN LVN (A). CNA (C) said, CN LVN (A) arrived and asked Resident #17 if she was hurt anywhere several times, Resident #17 said no. CNA (C) said, CN LVN (A), continued with her assessment, took the resident's vital signs, checked her head, and asked Resident #17 if she wanted to be sent out to the hospital. Resident #17 said no . CNA (C) said, she and the other aid assisted the resident up and got the resident up in her chair. During an interview on 10/27/2025 at 3:30PM, CNA (D) said on 08/09/2025 she was scheduled for a 6:00AM shift, she was asked to work hallway 200 (due to a CNA was a no show), CNA (D) stated when she arrived, she saw the disturbance and immediately went to Resident #17's room. Resident #17 was lying on the floor and immediately called for the CN LVN (A), she stated, the nurse checked the resident and recalled LVN (A) had asked Resident #17, three times, did she need to go out to the ER and Resident # 17 said no, and that she was fine. Both CNA (C), and CNA (D), identified that the call light was on when they arrived in the room, but was unsure of the length of time due to both CNA's were coming on for the 6AM to 6PM Shift. During an interview on 10/27/2025 at 4:00PM, CN LVN (A) named in the allegation said on 08/09/2025, she was scheduled for 6AM morning shift. While receiving reports and counting narcotics, an aide notified her that Resident #17 was found on the floor. She immediately went to Resident # 17's room, said approximated times was between 6:15AM and 6:30AM, she could not recall if the call light was ON or Off at the time of arrival to Resident # 17's room. LVN (A) said, the resident was in the entry doorway on the floor in a slight leaning position. LVN (A) said, at the time of the initial assessment, the resident was able to answer questions, denied hitting her head, vital signs were taken, no noted bruise or laceration, and the resident stated, that she was fine. LVN (A) said, she repeatedly asked Resident #17 if she wanted to go to the ER and the resident repeatedly said no. LVN (A) said the two CNAs assisted the resident back to her chair and the fall incident was reported to ADON, DON, physician and Resident #17's RP. LVN said, after the arrival of the resident's care givers later that morning, and the assistance of the resident up to be toileted, Resident # 17 complained of pain in the left ankle. LVN (A) said the resident's left ankle was noted to be slightly swollen, it was decided to send the resident to the ER to be further evaluated. 11:00AM Resident #17 was sent out via ambulance to the ER to be further evaluated. LVN (A) said she was suspended during the facility's internal investigation. Durning a phone interview on 10/28/2025 at 12:30PM with Resident # 17's Responsible Party/Caregiver she said on 08/09/2025 she was notified by the facility that Resident # 17 had fallen. She said she was Resident # 17's Responsible Party, and caregiver, and there was no family available. The RP caregiver said Resident #17 had an electronic monitor in her room and the video was reviewed by Prior Interim ADM and prior ADON. The RP/caregiver said you could see on the phone video that the call light was on, stated the video revealed Resident #17 called out for help, Resident #17 was sitting on the side of the bed, after waiting the resident got up and fell in her room by her bed. The surveyor requested video to be sent and reviewed on state phone. The RP/ caregiver agreed to send video to surveyor's states phone. The surveyor attempted twice to retrieve the capture video, after 24hr the Electronic Video was never received or reviewed by the state surveyor during investigation. During a phone interview on 10/29/2025 at 10:30AM CNA (E), named in the allegation, said on 08/09/2025, she worked the night shift and was scheduled on hallway 200. The CNA (E) said on the morning of 08/09/2025, she and the CN LVN (B) made rounds approximated 5:55AM, and said Resident #17 was in bed, and the resident call light was not on. She said she heard no one say help. CNA (E) said, the on-coming day shift CNA was a no show on the morning of 08/09/2025, and she notified the oncoming CN LVN (A) that she had to leave. The CNA (E) said she left the facility at 6:15AM. CNA (E) said two days later she was notified by Prior ADON that Resident #17 had fallen and to come in and give her statement of the incident. Both Prior Interim Admin., and prior ADON met with her in the meeting, and both said they had reviewed Resident #17's electronic video, but stated she never saw the video. CNA (E) said on 08/15/2025, she was suspended pending investigation and then terminated due to inaccuracies in her accounts of the events. Durning an attempted phone interview on 10/29/2025 at 11:30AM, CN LVN (B), named in the allegation was not interviewed after two attempts, surveyor was unable to make contact during investigation. Reviewed Prior ADON written statement: Prior ADON contacted LVN (B) requested employee to return to facility to complete a statement of the incident events. LVN (B) stated Yall have it all backward. Several attempts were made by Prior ADON to encourage employees to come to the facility to resolve the issue. Employee LVN (B), self-terminated 08/15/2025, due to failure to return to give statement of incident. Durning a phone interview on 10/29/2025 at 3:30PM the Prior Interim ADM and prior ADON said, they both had reviewed the RP/care giver provided video footage. Both prior staff members indicated that the video revealed Resident #17 was sitting on the side of the bed calling for help, and the call light button was on, the video clip time stamped approximated 5:17AM or 5:22 AM . They also witness Resident #17 fall on the floor but unable to recall the exact time of fall because the video clip was not time stamped. Both prior Adm., and ADON. said, the provider responded with safe surveys conducted. Scheduled observations of Resident #17 were performed for 72hr. Suspension of staff pending investigation, and termination of one employee. Both stated staff training on abuse and neglect, fall prevention, notifying administration of staffing shortage, and call light response times all were completed. During an interview on 10/29/2025 at 4:30PM the Current ADM said he was not on staff at the time of the incident, but stated, he had reviewed the incident report and stated he had initiated a plan of care, during morning reports to identify any resident's concerns, increased the staffing levels on the heavy hallways (from 2 CNA to 3 CNA's each shift), and hired a new staffing coordinator. In serviced staff on Abuse/ Neglect, falls prevention, call lights response time, and staff expectation stating, All staff are responsible for answering call lights, and reporting incidents. Review of facility policy for Falls prevention, Abuse & Neglect, Call light response time and customer service, revealed all seven (7) elements were addressed: Screening, Training, Prevention, Identification, Investigation, Protection and Reporting. There were no concerns with facility policy. In-services were reviewed and were compliant.

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 1 of 1 kitchen. Staff were not wearing bearded hair nets 3 large baking sheets containing carbon build-up were stacked against each other Large and medium steam table pans stacked on rack contained moisture and water on the inside and food particles on the inside The three compartment Sink was stacked and dirty with dirty pots and pans in all three compartments Steam Table dirty with food splatter on glass Dried blood on floor by handwashing sink with no soap and paper towels to wash hands Trash in multiple areas of kitchen debris Open packaged meat, in a 2-door refrigerator, was not labeled, was not in a sealed container. A 2-door refrigerator door left open with freezer residue on outside of the door Refrigerator/Freezer temperature logs had not been taken since 10/20/2025 Dishwasher test log, no test or evidence of test strips for sanitizing dishes, Dishwasher test log had been filled in and completed until end of monthCleaning log dated 09/2025 none for the month of October 2025The ice machine seal dirty with no mention of when had been last cleaned. This item was not listed to be cleaned on the cleaning facility log.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included: During observations on 10/27/2025, the following was noted in the kitchen: *At 9:00 AM both handwashing sinks for hand washing in the kitchen did not have soap nor paper towels to wash hands, the hand sanitizer before you enter the kitchen was empty/broken. *At 9:04 AM Dishwasher-E was not wearing a beard net. He said his beard net was in his pocket, was never seen wearing the beard net. He was observed running the dishwasher without testing the dip pan for proper sanitizer, he said he did not have the test stripes to do the sanitizer. *At 9:08 AM Cook-H said the dietary manager was not here. Upon identifying the cook: carbon build up on 3 large baking sheets stacked together on a rack, 3 large and 2 medium steam table pans stacked together on a rack with moisture and water on the inside of the pans, food particles on the inside of 2 of the large steam table pans. Cook-H said, I see what you are saying. I haven't worked here that long, and it has been built up over the years. I don't know what to say, I will let the dietary manager know. *At 9:13 AM An open package of meat in the 2-door refrigerator in the kitchen was unlabeled and was not enclosed in a sealed container. The door on the 2-door freezer was open with frost built up on the outside. A box of sweet roll dough with expiration date of 8/8/2025 was sitting on the counter to be used. DA G said she will let the dietary manager know. On a follow-up visit and interview on 10/27/2025 at 10:30 AM Cook-H and DA G said that they were not in-serviced on serving sizes and temperatures and now they found out that the DM had quit.During an interview with the Administrator and ADON, on 10/27/2025 at 10:35 AM, they both said Dietary manager did not have any documentation that staff have been in-serviced on kitchen sanitation. They said they could do it today and were not sure if all the kitchen staff had their food handler's certification but would find out. Both said they were not aware of the condition of the kitchen. *At 10:45 AM on 10/27/2025 Dish washer-F said he did not get trained on dish washing and will not use the dishes until he can prove that they are sanitized and ready for use. During an interview with the Administrator at this same time he said, they will use paper products until they get test strips to show proper sanitization. On a follow up visit and interview with FM/CNA J at 10/27/2025 at 11:00 AM, she said she was trained and able to handle the current situation of the kitchen, she now has serving sizes correct, temps recorded, and steam table cleaned. She has her food managers certification. *At 2:21PM on 10/28/2025, the HR director provided food handlers certification for all the dietary staff Review of facility policy for Food Preparation and Service dated revised November 2022. Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.

Based on interview and record review, the facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns for 9 of 13 confidential residents. The facility failed to ensure 9 of 13 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, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: During the record review of Grievance/Complaints on 10/29/2025 at 10am, 9 of 13 Grievances dated 8/12/25,8/13/25(2) 8/25/24,8/27/25,9/5/25(2),9/8/25 and 9/17/25 had not been followed up by Grievance Officer or Administrator.Interview with Resident Council President on, 10/28/2025 at 11:00am, stated that several Grievances had been filed and had not been responded back with replies from the Grievance Officer nor the Administrator. The Resident Council President stated from July 2025 meeting until October 2025 there have been several grievances filed with no response and when asked, the Grievance Officer would say, he will investigate it for her. Interview with the ADM on 10/28/2025 at 1:14pm; the ADM stated the SW was the Grievance Officer for the facility. The ADM stated the SW was responsible for the review of Grievances and assigned them to department heads. The ADM stated there was no system for submitting a Grievance form anonymously. Grievance forms are available for the Residents outside the SW's office; the Grievance forms were submitted to the SW by the Resident or their family member. The ADM stated the facility should resolve grievances as soon as possible once they were submitted. The ADM stated the procedure for submission of a Grievance was the SW assigned the grievance to the appropriate department, that department addressed the grievance, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the original Grievance form. The ADM stated completed Grievances 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 would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for ensuring staff were trained in the Grievance process. The ADM stated the potential negative outcome for Resident's not having a system to file Grievances anonymously was the Resident may not file a Grievance, and the issue will not be resolved. An interview with the Grievance Officer on 10/29/2025 at 10:30 am who was the SW, said he was responsible for the review of Grievances and assign them to department heads. The SW said there were several grievances that had not been addressed, he had given them to the interim ADM who he found out had not followed up on the grievances, but it was still the responsibility of the Adm/SW to follow up. An interview with the AD on 10/29/2025 at 11AM who assists the residents in filing grievances, she said that is all she does is assist the residents and after it is filed, she has no idea of what happens. Record Review of the Grievance Policy revised January 2017 reflected the following: Policy Statement Residents, family, and resident representatives have the right to voice or file grievances, either orally or in writing, to the facility staff or the agency designed to hear grievances (e.g. the state Ombudsman) You are requested to follow the procedures outlined below when filing grievance or complaint: 1. Any resident, family member or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility.2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form and without fear of discrimination or reprisal.3. All grievances, complaints or recommendations stemming from residents or family groups concerning issues of residents' care in a facility will be considered. Actions on such issues will be responded to in writing including a rational for the response.4. The administrator has delegated the responsibility of grievance and or complaint investigation to the grievance officer5. Within five (5) working days of the date you filed the grievance; you will be notified of the results of the investigation. (Note: Complaints of abuse, harassment, or mistreatment will be immediately investigated, and you may request a report of the findings, recommendations, and/or corrective action taken within five (5) working days of the filing of the report.)6. It is the policy of this facility to assist you in filing a grievance or complaint. Should you feel that our staff has not assisted you in this matter, or you feel that you are being discriminated against for taking such steps, you are encouraged to report such incidents to the Administrator at once.7. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of residents' rights while the alleged violations are being investigated.

Based on observations, and interviews, and record review the facility failed to serve food that was palatable for 1 of 1 meal reviewed for food palatability. (noon meal 10/28/2025). The facility did not provide palatable and appetizing food for the residents for the 10/28/2025 noon meal. Residents #1, 3, 4, 6, 11, 14, 15 and 19 complained of cold food and food that was not flavorful. These failures could place residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake.Findings included: 1.During interviews during the initial tour on 10/27/2025 the following was noted: *At 9:46 AM Resident #11 said the food was very cold and very salty at times. *At 9:50 AM Resident #3 said the food was bad. *At 10:09 AM Resident #4 said the food was not that good. *At 10:31 AM Resident #6 said the food was not good. *At 10:33 AM Resident #15's family member said the food here was not very good. *At 10:35 AM Resident #19 said the food was not the greatest lately. **At 11:17 AM Resident #14 said the food is just ok. 2. During observations on 10/28/2025 at 12:00 PM the test tray left the kitchen after the dining room was served, and was hand delivered by the RD. The test tray for the surveyors. On 10/28/2025 at 12:10 PM the test tray arrived in the work room. The plate of food was on a tray and covered with a hard plastic cover. The RD was present with the tasting of the food. The following were found: *Regular tray- spaghetti with thick noodles, tossed green salad, and a garlic bread stick. Spaghetti was cool, seasoned ok. [NAME] tossed salad cool Garlic bread was hard No dessert on trayNo drinks on tray The second test tray which came after the last hall trays were served on 10/28/2025 at 12:30 pm Spaghetti was cold, seasoned ok. [NAME] tossed salad cool Garlic bread was hard difficult to chew Cup of diced peaches with whip cream on top - coolNo drinks on tray During an interview on 10/28/2025 at 12:30pm The RD agreed with the findings. The spaghetti on the regular tray was not hot, and seasoned ok, the bread stick was hard difficult to bite into, no dessert and no drink. The second test tray's Spaghetti was cold, seasoned ok. [NAME] tossed salad cool. Garlic bread was hard difficult to chew. Cup of diced peaches with whip cream on top - coolNo drinks on tray 4. During interviews on 10/28/2025 the following statements were made regarding the noon meal of spaghetti, salad, bread stick and peaches with whip cream: *At 11:35 AM Resident #11 said it's food, but it's not good. She said, I may eat a little of it. *At 11:36 AM Resident #3 said it may look good, but it never tastes good, she said it is always too spicy. *At 11:49 AM Resident #14 said he was going to eat some of the meat. He said he didn't want the rest of it, and he wished they would improve on the food. *At 1:05 PM Resident #1 said her lunch food was cold and very salty. *At 1:20 PM Resident #19 said it probably would have been good if it were not cold and they don't give me enough. *At 1:25 PM Resident #6 said the food was just ok. She said it was not like home cooked food, she said she always has to wait on her tea, and it is never hot. During an interview with the Administrator on 10/27/2025 at 9:30 AM he said that the dietary manager had called in this morning 10/27/2025 and gave her notice to quit and he currently did not have a dietary manager and his thoughts were that, each resident should be 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, that 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. The Administrator said this deficiency cold put the resident at risk for weight loss, and multiple dietary issues. Record Review of the facility's policy for Food Preparation and Service dated revised November 2022 documented the following: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices

Based on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 2 of 3 residents (Resident #1 and Resident #2) reviewed for tracheostomy care. The facility failed to ensure proper care was provide to Resident #1 on [DATE] when she was in respiratory distress due to her tracheostomy's inner cannula (a removable, cylindrical tube that fits inside the outer cannula of a tracheostomy tube) being obstructed resulting in Resident #1 being hospitalized . The facility failed to ensure they had full-time qualified staff to perform proper tracheostomy care on Resident #2's tracheostomy in accordance with professional standards. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 3:20 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious harm, impairment, or death. Findings Included: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including cardiac arrest, cerebral infarction (ischemic stroke), pneumonia, hypertension, cough, and pulmonary edema (a condition caused by excess fluid in the lungs). Record review of the MDS dated [DATE] indicated Resident #1 was usually understood by others and understood others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated Resident #1 had a tracheostomy and required suctioning. The MDS indicated Resident #1 experienced shortness of breath or trouble breathing when lying flat. Record review of the care plan revised on [DATE] indicated Resident #1 had a tracheostomy and was at risk for complications/infections with interventions including extra emergency trach and ambu bag (a portable device that delivers positive pressure ventilation to patients who are breathing inadequately or not at all) kept in room/ bedside at all times, if inner cannula becomes dislodged call 911 immediately, place oxygen over the tracheal stoma (an artificial opening created in the front of the neck to provide an airway for breathing), and give extra cannula to EMT upon arrival. Record review of the nursing progress note written by LVN A on [DATE] indicated, .I went to suction [Resident #1] and had resistance, and no visible mucous came out from this [Resident #1's] trach which alarmed me. [Resident #1] said help me, I then ran to get the weekend supervisor and asked for her pulse ox (an electronic device that measures the saturation of oxygen carried in the red blood cells) and asked her could she come help me further assess [Resident #1]. The pulse ox read 77% (normal oxygen level is ,d+[DATE]%) and [Resident #1] appeared in distress so I called 911, while they were on the phone we then reassessed [Resident #1's] vitals her [oxygen] then read 56% and he [blood pressure was] ,d+[DATE] (normal blood pressure is ,d+[DATE]). EMT arrived in the room right when [Resident #1] went unresponsive and wanted to check for pulse before initiating CPR. No pulse was detected this nurse performed chest compressions until EMT got their equipment out and took over. EMT asked this nurse to try and suction [Resident #1] still nothing would come out, EMT tried to use the ambu bag on [Resident #1] and could not get air through, EMT then asked for a spare trach I grabbed it from the box, when he removed the current trach it was visibly clogged with mucous. This nurse then suctioned [Resident #1] and was able to get yellow blood tinged mucous. EMT was then able to get the bag to function properly and a pulse. [Resident #1's] mouth filled with foamy saliva. I then suctioned [Resident #1's] mouth and EMT did the last of their assessment and transferred [Resident #1] to [the] emergency room . Record review of the hospital records from Resident #1's admitted [DATE] indicated Resident #1's active hospital problems included cardiac arrest with assessment: suspect respiratory cause due to mucous plugging and acute and chronic respiratory failure with assessment: suspect cause due to mucous plugging. Record review of the facility's discharge summary dated [DATE] indicated Resident #1's discharge date d was [DATE] with the reason for discharge being Resident #1 passed away at the hospital. The discharge summary indicated Resident #1's discharge date was [DATE]. During an interview on [DATE] at 12:37 p.m. the Medical Director said he was familiar with Resident #1. The Medical Director said Resident #1 had gone to the hospital for cardiac arrest while in the facility and returned to the facility with a tracheostomy and feeding tube. The Medical Director said if a nurse attempted to suction a resident, met resistance, and no visible mucous was removed it seemed reasonable, and he would assume it was standard practice, to remove the inner cannula of the trach and ensure there was no obstruction. The Medical Director said an obstruction such as a mucous plug would cause a decrease in oxygen saturation and increase in blood pressure. The Medical Director said he was aware Resident #1 had passed away but was unaware of the exact date or cause of death. During an interview attempt on [DATE] at 12:16 p.m. LVN A did not answer the phone and the surveyor was unable to leave a voicemail. During an interview attempt on [DATE] at 12:17 p.m. RN Weekend Supervisor B did not answer the phone and the surveyor was unable to leave a voicemail. Record review of the Tracheostomy Validation Checklist dated [DATE] indicated LVN A correctly answered the question regarding signs and symptoms of airway obstruction or infection. Record review of the Tracheostomy Care Validation Checklist dated [DATE] indicated LVN A satisfactorily demonstrated trach care including removing and cleaning an inner cannula of a tracheostomy. 2. Record review of the face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old-male readmitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, tracheostomy status, and pneumonitis (inflamed lung tissue) due to inhalation of food and vomit. Record review of the MDS dated [DATE] indicated Resident #2 was rarely/never understood by others and rarely/never understood others. The MDS indicated Resident #2 did not have a BIMS completed. The MDS indicated Resident #2 had a tracheostomy and required suctioning. The MDS indicated Resident #2 experienced shortness of breath or trouble breathing when lying flat. Record review of the care plan revised on [DATE] indicated Resident #2 had a tracheostomy (Bivona (Bivona tracheostomy tube is a silicone tube designed for airway management, featuring a cuff that, when inflated, creates a seal between the tube and the trachea to protect against aspiration and optimize respiration) size 6) related to impaired breathing mechanics, respiratory failure and is at risk for complications/infections with interventions including extra emergency trach and ambu bag (a portable device that delivers positive pressure ventilation to patients who are breathing inadequately or not at all) kept in room/ bedside at all times, if inner cannula becomes dislodged call 911 immediately, place oxygen over the tracheal stoma (an artificial opening created in the front of the neck to provide an airway for breathing), and give extra cannula to EMT upon arrival. During an interview on [DATE] at 10:50 a.m. the DON said that the nurses in the facility did not remove and clean cannulas for trach patients. The DON said only the RT could remove or change a cannula. The DON said if a trach cannula became dislodged nurses were required to call EMS and could not reinsert the cannula. The DON said the facility had a RT on staff PRN who came in once a week to change/clean trachs. During an interview on [DATE] at 11:02 a.m. the DON said he thought the surveyor was asking specifically about Resident #2's trach which was a Bivona trach when asking about removing and cleaning tracheostomies and cannulas. During an interview on [DATE] at 11:03 a.m. the Regional Nurse said nursing staff could and were expected to perform trach care including removing, disposing of, and replacing inner cannulas for residents who have a Shiley trach (a tracheostomy tube that uses an inner removeable cannula). The Regional Nurse said if when suctioning a tracheostomy and resistance was met and no mucous was being suctioned out, she would expect the nurse to remove the inner cannula, check for a mucous plug in the cannula, and replace with a new inner cannula. The Regional Nurse said if a resident was in respiratory distress, she would expect the nurse to call for EMS and do everything they could in the meantime including changing the inner cannula to ensure the resident's airway as much as possible. The Regional Nurse said it was out of nurses' scope of practice to remove or change a Bivona tracheostomy. She said it had to be performed by EMS or an RT. Record review of the facility's Tracheostomy Care policy dated ,d+[DATE] indicated, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive care plans and resident goals and preferences .The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. Tracheostomy care will be provided according to the physician's orders, comprehensive assessment and individualized care plan such as monitoring for the resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate .The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice . The Administrator was notified on [DATE] at 3:38 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 3:42 p.m. The facility's Plan of Removal was accepted on [DATE] at 9:00 a.m. and included: Alleged Issues: The facility failed to ensure proper care was provided to Resident #1 when she was in respiratory distress due to her tracheostomy's inner cannula was obstructed. The facility failed to ensure they had full time qualified staff to perform proper tracheostomy care on Resident #2's tracheostomy in accordance with professional standards. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: The Director of Nursing, Clinical Support Specialist, and VP of Clinical Operations will deliver all following in service education to nurses one on one. 1. Nursing staff will be in-serviced to respond to medical emergencies for residents, when their tracheostomy becomes clogged, a mucus plug is identified, or resident is having difficulty breathing. This in-service was initiated on [DATE] by the Director of Nursing. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. The Director of Nursing, Clinical Support Specialist, and VP of Clinical Operations will deliver all following in service education to nurses one on one. This in-service includes, In: the event of an emergency with a resident that has a tracheostomy, you attempt to suction and are unable to clear the mucus plug, IMMEDIATELY REMOVE THE INNER CANNULA AND REPLACE IT. IF THERE IS NOT AN INNER CANNULA, YOU MUST DECANNULATE THE OUTER CANNULA AND REPLACE IT. This should clear the airway enough to suction the mucus out. There will be an emergency inner cannula in the box at the beside with an ambu bag, and extra trach for EMS if needed. Immediately call your DON, provider, and RP. Document all findings 2. The facility Medical Director was informed of the IJ on [DATE] by the VP of Clinical Operations. 3. Resident #1 expired in the hospital [DATE]. 4. Resident #2 will be provided for appropriately, with having all nurses trained in decannulation/re-cannulation of tracheostomy, in the case of a mucus plug/blockage, by the facility respiratory therapist, or by the Director of Nursing, who will be trained by the facility respiratory therapist on [DATE]. 5. The Director of Nursing, Clinical Support Specialist, and VP of Clinical Operations will deliver all following in-service education to nurses one on one. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. This will begin immediately, [DATE]. Competency with return demonstration will be completed by [DATE]. No nurse will be allowed to work on the floor until their competency is completed. 6. The DON will review new hire orientation packet to ensure these above in-services are completed prior to the first shift on the floor, including tracheostomy competencies including decannulation/re-cannulation emergency procedures. The VP of Clinical Operations provided this in-service to the Director of Nurses on [DATE]. 7. Facility policy was updated to reflect decannulation and re-cannulation of tracheostomy is necessary in an emergency situation where the airway is compromised by a mucus plug, and the suction catheter meets resistance by the VP of Clinical Operations on [DATE]. 8. Physician orders added to each resident with a tracheostomy, to include, may decannulate and re-cannulate tracheostomy if unable to establish patent airway or mucus plug present, per LVN/RN by the VP of Clinical Operations on [DATE]. 9. Resident orders updated to include a tracheostomy one size smaller to be included in emergency supply box at bedside, by the VP of Clinical Operations on [DATE]. The facility does have tracheostomies one size smaller available in the facility at this time for all residents in the facility with tracheostomies. Monitoring: The 24-hour report in the EMR which runs all progress notes in real time, will be monitored daily in the clinical meeting for changes in condition by the clinical team, DON/ADON/MDS. The DON or designee will perform random in person audits with nursing staff to ensure they understand the tracheostomy decannulation/re-cannulation procedure, at least 3 nursing staff weekly X1 month. This process will begin [DATE]. DON/ADON's will make rounds daily Monday-Friday, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure no changes in condition are in progress regarding trach status. This process will be ongoing effective [DATE]. Assessment: The Director of Nursing and VP of Clinical Operations viewed each resident with a tracheostomy to ensure all emergency supplies were present at bedside on [DATE]. QAPI Committee review: An interim QAPI committee meeting was completed on [DATE]. IDT will review for compliance monthly in QAPI X3 months. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation and interview on [DATE] at 9:00 a.m. the DON showed the surveyor the trach supplies at bedside for 2 of 2 residents currently in the facility with tracheostomies. The supplies were observed to contain a tracheostomy the same size and one size smaller for each resident. The DON said staff training had started on [DATE]/5 and would continue ,d+[DATE] times weekly for 1 month and then as needed. The DON said he would be documenting the trainings and reviews. Record review of orders, effective [DATE], for 2 of 2 residents currently in the facility with tracheostomies indicated, If tracheostomy becomes blocked with mucus plug, nurse is not able to advance suction catheter due to blockage, the tracheostomy must be decannulated, and re-cannulated immediately. Two nurses or a nurse and RT must be present to complete procedure. As soon as new tracheostomy is in place, and patent airway established, call 911 and send to ER and orders also indicated tracheostomy supplies would include a tracheostomy one size smaller than the resident currently had in place. Record review of the facility's Tracheostomy Decannulation policy dated [DATE] indicated, Decannulation of a tracheostomy tube can occur accidently or may be indicated when a resident no longer requires the use of a tracheostomy tube. Policies and protocols to address accidental or planned decannulation of a tracheostomy tube will be based on professional standards of practice and carried out by trained clinicians in accordance with Federal, State, or local guidance, regulations, or State practice acts/laws .Clinicians with training in accordance with State practice acts/laws may only reinsert a tracheostomy tube if accidental decannulation occurs, or emergency blockage is in place, in an established stoma as per facility protocols .Ensure that the resident has a spare tracheostomy tube with obturator in the correct size and one size smaller available at beside at all times. Record review of Tracheostomy Care-Changer Inner Cannula/Outer Cannula Skills Checklists dated [DATE]-[DATE] indicated the DON, LVN C, LVN D, LVN E, the Treatment Nurse, and LVN F were checked off by the RT and LVN G, LVN H, LVN J were checked off by the DON. Record review of the QAPI sign-in sheet dated [DATE] indicated the facility had a QAPI meeting regarding the IJ with meeting attendees including the Medical Director, Administrator, DON, and Regional Nurse. Staff interviewed (DON, RN K, LVN G, LVN J, Treatment Nurse, and LVN F) who worked across all shifts on [DATE] from 9:00 a.m. to 10:22 a.m. were able to verbalize what to do in the event of meeting resistance and not getting an visible mucous out when suctioning a tracheostomy including removing the inner cannula of tracheostomies with inner cannulas to remove any obstruction or with the assistance of another nurse decannulating a resident and re-cannulating a resident with a tracheostomy that did not have an inner cannula to remove any obstruction. Staff interviewed said the importance of ensuring tracheostomies did not have an obstruction was to maintain a patent airway. On [DATE] at 10:30 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the residents advanced directives for 1 of 4 residents reviewed for emergency care. (Resident #1) 1. Resident #1 a full code status ( a medical code status that indicated to take all steps to save the residents life in the event of cardiac or respiratory arrest, including CPR) turned blue and had no pulse or heart rate, the facility staff requested the crash cart (a cart with emergency medical supplies) when the cart arrived the emergency supplies were missing. 2. The crash cart did not have AED pads for the AED- defibrillator (AED pad are a vital part of the AED machine that are used to help people experiencing sudden cardiac arrest. The AED pads are place on the person's bare chest and are attached to a cable that connects to the AED to the patient body. The AED then analyzes the hearts rhythm and can deliver an electric shock or defibrillation, to help the heart re-establish normal rhythm.) and they did not have an ambu bag- bag mask ventilation ( the primary tool for resuscitation in emergency situations such as cardiac arrest). 3. The facility failed to have emergency equipment at the Resident #1's (a tracheostomy resident) bedside as ordered by the physician to include an extra tracheostomy and an ambu bag. The facility nurses did compressions only. 4. Resident #1 was without oxygen to her brain for about 10 minutes prior to EMS arrival and remained unresponsive after she was resuscitated. Resident #1 was placed on hospice due to severe brain damage. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for not receiving CPR services as needed and being at risk for death. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated this [AGE] year-old female was admitted to the facility on [DATE]. Some of the diagnose were acute respiratory failure, and morbid obesity. Record review of Resident # 1's baseline care plan dated [DATE] indicated she was a full code ( CPR to be preformed) other than that the form was basically blank. Record review of Resident #1's care plan dated [DATE] indicated a Focused area of Full Code. Some of the interventions were the resident would receive CPR if indicated, and to continue CPR until resident responded or until EMS arrived to take over the code. A Focused area tracheostomy status and was risk for increased secretions, congestion, respiratory infections, and infections to tracheostomy. She required a trach Bovina(name brand) flex 7 humidification with air compression at 50 PSI OS at 8 liters per minute via trach collar. Some of the interventions were Ambu bag and an extra inner cannula along with 1 size smaller to be kept at the beside. Monitor oxygen stats and apply oxygen as ordered. Monitor for needed suctioning of increased secretions, congestion assessed for relief. Record review of Resident #1's MDS dated [DATE] titled other was incomplete. Record review of Resident #1's computerized physician orders indicated BiPap/APAP to be worn at night on at night off in the mornings with setting specified. An order for trach bovina flex 7 extra of that size and one size smaller to be kept in supply box at bedside dated [DATE]. The resident required Foley catheter care every shift. May change disposable inter canula of trach daily, emergency trach supplies are to be kept at bedside to include oxygen source, suction machine, additional trach and ambu bag. Record review of nursing notes dated [DATE] at 7:57 p.m. indicated Resident #1 arrived at the facility via EMS. The resident was alert and oriented to self, time, place, situation, and able to make her needs known. She was a full code. Her vital signs were within normal limits, and she voiced no pain. Record review of a RT note dated [DATE] at 3:41 p.m. indicated Resident #1 was placed on a speaking value and trach was suctioned. Suctioned a small amount of thin white secretions. The patient tolerated the treatment well. Nursing staff on duty instructed on how to place the speaking valve. Time spent 25 minutes. Record review of nursing note dated [DATE] at 3:00 a.m. indicated at 2:15 a.m. CNA called nurse to the room. LVN B went into the room and the resident stated she could not breath and wanted to be switched to her humidified oxygen. LVN B attempted to suction the resident with no secretions removed. The resident went unresponsive with no pulse and no respirations. CPR was started and the crash cart obtained, AED pads applied and 911 called. EMS arrived and CPR continued at 2:32 a.m. pulse obtained but resident continued to be unresponsive, and breaths given via ambu bag continued per EMS instructions. At 2:43 a.m. the resident was transferred to stretcher, and continued to be unresponsive, pulse continued, continued to administer breaths via ambu bag. At 2:45 a.m. resident transferred to hospital. note signed by LVN A. Record review the facility crash cart check off list [DATE] indicated on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] there were no check offs for those days and the form was not initialed. The rest of the days and the days in between were checked and the form was initialed. Record review of the facilities crash cart check off list for [DATE] indicated there was one day that the form was not signed [DATE] all other days were checked as if the supplies were there and signed. Review for the facility crash cart check on [DATE] at 11:43 a.m. of list for [DATE] indicated on [DATE], [DATE] and [DATE] the slot for ambu bag was circled and checked. All the other dates except [DATE] we checked and initialed. On [DATE] it was not checked or signed. Record review of an EMS report dated [DATE] indicated they were called at 2:17 a.m. They arrived at the facility at 2:24 a.m. and they were at the patient at 2:25 a.m. The facility staff said Resident #1 had only been at the facility for two days. They reported that they were not familiar with her. The staff reported Resident#1 hit her call light and told them she was having breathing problems. The resident had no emergency trach at bedside. All the staff members denied her being their patient and was unable to locate the patient caregiver.( LVN A) The staff reported the patient stated to turn blue before going into cardiac arrest surrounding 2:15 a.m. The fire department was requested by EMS for lift assistance and possible riders due to the patient, not fitting. The report indicated they arrived at the patient side to find [AGE] year-old female lying in bed with CPR being performed. The patient is pulseless and had her ventilator providing resume breaths. Her face appeared purple and warm and dry skin touch. A rapid assessment was performed and findings were noted on the assessment. The patient was removed from the vent and placed on ambu bag. Staff were informed and squeeze ambu bag about every six seconds. The patient was applied to monitoring devices via stat pads and found with no heart rate. The staff were struggling when attempted to use the ambu bag on the resident. The staff member was using two hands to squeeze. EMS attempted one ventilation switch to replacing the trach. EMS was informed the patient did not have any emergency trach on standby. EMS used the adult [NAME]( a tool used to unclog trach) and forced it past the clotted mucus plug. EMS suction the place the patient back on the bag. The [NAME] was covered in thick nasty mucus. Ambu bag is now easy to squeeze without issue. Staff informed to breathe with ambu bag about every three seconds until she resumed her normal breathes. EMS quickly obtained return of spontaneous circulation ( resumed heart rate) and the fire department was called to assist. EMS interventions continued as noted above. Record review of Resident #1 hospital records dated [DATE] indicated per admitting providers documentation. Resident #1 was a [AGE] year-old female with a history of diabetes, high blood pressure, morbid obesity, tracheostomy, and feed tube. She presented to the emergency department via nursing facility care on [DATE] after a cardiorespiratory arrest. Per nursing home staff, the patient complained of shortness of breath and having difficulty breathing and became unresponsive with no pulse. They initiated CPR with an approximated downtime of 10 minutes prior to EMS arrival. EMS gave one round of epinephrine (used to improve breathing and stimulate the heart.) Resident #1's heart rate resumed and she was transported to the emergency room . In the emergency department she was placed on mechanical ventilation via trach. She was admitted to the ICU after cardiorespiratory arrest. The patient was not waking up despite no sedation medications provided. On [DATE] the patient remained on mechanical ventilation with the assisted control and possible seizure disorder. On [DATE] and MRI of the brain was completed and indicated acute encephalopathy due to Anoxic( complete absence of oxygen in an organ or tissue) and brain injury. During a telephone interview on [DATE] at 10:00 a.m., LVN A said Resident #1 was her resident on the morning of [DATE]. She said she had went to lunch and was gone about 15 minutes. When she arrived back at the facility LVN B and LVN C were performing CPR on Resident #1. She said EMS was already there when she got back. She said LVN B and LVN C did 3 or 4 rounds of just of compressions, EMS got Resident #1 suctioned. LVN A said when EMS suctioned Resident #1 a lot of blood came out. She said EMS connected the ambu bag to the trach. During a telephone interview on [DATE] at 10:45 a.m., LVN A said Resident #1 did not have a trach at her bedside because she did not see one. She said she did not think EMS asked for one. She said CNA D called LVN B to say Resident #1 was having difficulty breathing. LVN B told her when she arrived in the room and Resident #1 was talking and when she removed the Trilogy respiratory system from her and tried to suction her Resident #1 coded. She said then they started CPR . During a telephone interview on [DATE] at 1:00 p.m., CNA D said she and CNA F were walking down the hall and Resident #1 started screaming she could not breathe. She said LVN B came into the room and tried to fix her oxygen. CNA D said that did not work, and Resident #1 was turning blue. She said LVN B screamed for LVN C to get the crash cart. She said when they got the crash chart, she knew they could not find something, but she did not know what it was. During a telephone interview on [DATE] at 1:05 p.m. CNA F said she and CNA D were walking down the hallway on the morning of [DATE] about 2:00 a.m. They heard Resident#1 say she could not breath. She said LVN B came in and started checking Resident #1's tubes. She said LVN B began to try to suction Resident #1, and suctioning did not work. She said Resident started turning blue. She said LVN B began CPR and she and LVN C called for the crash cart. CNA F said there were no AED Pads and no Ambu bag on the crash cart. She said when EMS arrived, they had those things. She did not know if EMS was looking for anything else or not. During a telephone interview on [DATE] at 1:09 p.m. LVN C said she was down the hall and LVN B screamed her she had a code. She said LVN B was in Resident #1's room and she was a new patient. LVN said she knew nothing about the lady. She said when she arrived in the room Resident#1 was turning blue. She said LVN B was starting CPR and they got the crash cart. She said there were no AED Pads and no ambu bag on the crash cart. She told the other nurse to call 911. She said EMS was very quick to respond. She said they did not go the storage room to look for an ambu bag or AED pads. She said they spent their time trying to save the residents life. LVN C said Resident #1 was a large lady it took both to do compressions and try to suction her. She said when EMS arrived, they put the Ambu bag on Resident #1. She said at first the bag was hard to squish it because there was no airflow. She said they were able not to suction her, however, EMS had a tool to remove the mucus plug with. She said when the former DON was at the facility, she was informed they did not have ambu bags, AED pads and supplies. She said since the new DON arrived, they have all the supplies. She said she did not know if Resident #1 had an extra trach at bedside or not. She was on the other side of the bed. She said EMS did ask if Resident # was either one of the nurses' patients and she was not. She said Resident #1's nurse was on break.(LVN A) She said she did not know if EMS asked for a trach or not, she barely knew Resident #1's name. During an interview on [DATE] at 1:22 p.m. the VP of Clinical Operations said she took the position as acting DON [DATE] and was informed that day the supplies were not on the crash chart. She said she did do an impromptu in-service about the crash cart and supplies. She said she did not conduct a formal in service because she thought the items were used on [DATE], she did not realize they did not have them to use. The VP said she checked the crash cart to make sure it had everything in place and had since she took the position. She had found the ambu bags in a box in the storage room. Thy did not have any AED pads. The VP said she ordered them one day and they were delivered the next day. She said staff members told her the former DON said the items were on back order, however she did not have a problem getting them. She said they now have extra everything. During a telephone interview on [DATE] at 10:35 a.m., LVN B said she heard beeping and was at the nurse's station. She said she saw the call light go off and headed down the hall. She said she did not hear the resident say anything she mouthed the words. She said Resident #1 said I can't breathe. She said the alarm on the machine was going off as well. The machine read low pressure. She said the resident asked her to please switch her off the ventilator. She said before she could hook the resident up to the humidifier the resident lost pulse. She said the first minute or so the resident had a faint pulse. She said they were unable to get any air into Resident #1's airway because the airway was blocked. EMS unclogged the mucus plug and they were then able to use the ambu bag to get air into Resident #1's lungs. She said a couple of times it appeared Resident #1 took a deep breath. She did not know how long Resident #1 went without air in her system. She said she did not know if the ambu bag would have helped because the airway was completely blocked. LVN B said she could not say if the mucus plug could not have been loosened sooner with the ambu bag. She said there was no ambu bag at the bedside and no ambu bag on the cart. When the cart arrived, there were no AED pads. She said she was told a few days prior the ambu bags and AED pads were on back order by the former DON. She said she checked the cart on the night shift and knew the supplies were not on the cart. She said they had been out of those supplies for a few weeks but were always told they were on back order. She said she had circled a few days when the supplies were not available. ( Review of the log showed days circled were [DATE], [DATE] and [DATE].) During an interview on [DATE] at 12:00 a.m . the VP said she did not know what circles on the crash cart check log meant. She said she did not know how long the supplies were missing from the cart. During an interview on [DATE] at 11:10 a.m., LVN I said she started work at the facility on [DATE]. She said on [DATE] she was shadowing LVN A. She said the nurse had left the facility and she was in the hallway when she her heard LVN B yell she needed help with CPR. She said she had went into Resident #1's room and she did not see a trach on her bedside table. She did not remember if EMS asked for a trach or not. She said when the crash cart was arrived there was no ambu bag or AED pads. She said the staff were unable to use the AED machine and they just did compressions u ntil EMS arrived. She said the resident was probably not breathing for 8 to 10 minutes with no pulse. During a telephone interview with Resident #1's family member on [DATE] at 4:00 p.m., the family member said they were told prior to Resident #1 coming to the facility she would only be there for a couple of weeks. They said she was doing well with the trach and the hospital staff said she would likely be able to breathe on her own and have it removed in a few short weeks. The family member said when they arrived at the hospital on [DATE] they were in the room with the physician when he called the facility to ask how long Resident #1 was without oxygen to her brain. She said the physician was told by some nurse about 10 minutes. The family member said the physician was trying to determine why Resident #1 was still unresponsive. The family member said the doctor said it was due to lack of oxygen to her brain for an extended period. She said they were basically told Resident #1 had no hope of survival and was brain dead. The family member said they removed Resident #1 from life support on [DATE] and the moved her to hospice inpatient services on [DATE]. The family member said Resident #1 was still breathing and that was all. The family member said Resident #1 did not respond in anyway, she was just lying in the bed breathing. Record review of the facility's, emergency crash cart and automated extended defibrillators policy, dated [DATE], indicated it was the policy of the facility to ensure that the facility would maintain at least one emergency cart per nursing care floor with additional carts added as deemed necessary in the case of the need for basic life support. In addition, the facility would ensure that at least one AED was available for use in the case of cardiac emergencies. The purpose of this policy was to ensure that all supplies critical to basic life support were readily available on the emergency cart. The facility would store the emergency cart in a location that was readily accessible outside of the office. Equipment supplies for the emergency crash cart or used only when an emergency was provided. Emergency supplies used for an emergency from the crash cart are noted and replace promptly. The emergency cart would be checked every 24 hours and after every use. Missing or expired items were replaced when applicable. The AED was authorized for personal certified in CPR and use of the AED. The AED will be checked every night shift and the battery replace according to manufacturer's recommendations. Follow manufacturer instructions to use of the AED. Clinical staff would be educated on the location use of the emergency cart and the AED. Nursing staff should be familiar with the contents located on and within the emergency card. Record review of the facility's cardiopulmonary resuscitation policy, dated [DATE], indicated it was the policy of the facility to adhere to resident rights to formulate advance directives in accordance with those rights this facility would implement guidelines regarding CPR. The facility will follow American Heart Association guidelines regarding CPR. The website for the American Heart Association indicated reflected performing lifesaving CPR procedures include chest compressions, AED- defibrillator, Ambu- bag mask ventilation, intubation that can produce aerosols. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:00 PM. The Administrator and VP of Clinical Operations were notified. The ----- was provided with the IJ template on [DATE] at 4:05 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 1:22 p.m.: Problem: F678 Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directives. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. All nurses will be educated on the crash cart policy and where to find emergency medical equipment to perform CPR. All equipment required, including but not limited to, Ambu bag, AED, AED pads, and emergency tracheostomy cannulas, (size according to the resident orders), will be available for use in the facility, and at the bedside of tracheostomy residents, and on the crash cart. Approaches: The VP of Clinical Operations, Clinical Support Specialist, and ADON will deliver in service education to nurses one on one. 1. The facility medical Director was informed of the IJ on [DATE] during an Ad Hoc QAPI meeting, by the VP of Clinical Operations. 2. Resident #1 remains in the hospital. 3. Ambu bags, AED, AED Pads, and extra emergency tracheostomy cannulas are available in the facility and on the crash cart, verified by the VP of Clinical Operations on [DATE]. 4. Resident #2 has emergency Ambu bag, emergency tracheostomy cannula in a designated red and black tool box, labeled Ambu bag and extra trach, at the bedside, placed by the VP of Clinical Operations on [DATE] . 5. Each resident in house with a tracheostomy has the emergency box with supplies at the bedside, placed by the VP of Clinical Operations on [DATE]. There are currently 2 residents in house with tracheostomy's . 6. There are extra emergency Ambu bag toolboxes in the medication room for future residents with tracheostomy's, to be utilized on admission to facility. Nurses were in serviced by the VP of Clinical Operations on [DATE] regarding the new emergency toolboxes. All nurses will be in serviced on this new system before they are able to return to facility for their shift. 7. All nurses were in-serviced by the VP of Clinical Operations regarding checking the crash cart every night to ensure all items are present on the crash cart according to the emergency crash cart checklist, and any items missing from the crash cart, to notify the DON immediately, so the items can be replaced on the crash cart. Also included on the in-service was for the nurses to leave any items that are missing from the crash cart, unchecked on the crash cart log. This in-service was initiated on [DATE] by the VP of Clinical Operations. All nurses will be in-serviced on this system prior to returning to their shift. 8. All nurses will be educated on the Crash Cart policy and policy for ensuring emergency equipment for tracheostomy residents including Ambu bag and emergency trach care at the bedside of tracheostomy residents. The facility respiratory therapist educated all nurses on the use of the Ambu bag in case of respiratory distress during the on site training on [DATE]. All nurses will be in-serviced on this policy before they return to facility for their next shift by the facility respiratory therapist or RN trained by the facility respiratory therapist before beginning their next shift. 9. All nurses on staff at this time besides one that is in the hospital, have been in-serviced by the VP of Clinical Operations on [DATE]. All nurses will be in-serviced on this policy before they return to facility for their next shift. Monitoring: All new nurses will be educated on the policy for crash cart and emergency tracheostomy supply boxes prior to starting their shift. This information will be included in the orientation packet. Will review for compliance monthly in QAPI X3 months. The DON/designee will monitor daily to ensure all items are present on crash cart and the nurse who checked the crash cart initials are on the crash cart log. Nurses call the DON with any missing items. During observations on [DATE] at 7:15 a.m. with the VP revealed the crash cart was full stocked with AED pads and two ambu bags, and the crash cart check off list was signed. The DNR list was completed on [DATE] . During an interview on [DATE] at 1:15 p.m., the VP of Clinical Operations said she conducted a training with the Administrator, ADON, and the MDS nurse about the supplies being available for emergency use. They were informed if the supplies were low to order them. If there was a problem with receiving the order to notify her. She said they should have the trach at the bedside to give to EMS so they could replace it or take it to the hospital with the residents. She said the staff were in serviced on the crash cart, checking it, making sure supplies were available. They were informed if supplies were not there to notify the DON. During an interview on [DATE] at 1:29 p.m., the Administrator said she was in serviced on the crash cart and missing supplies. She said if anyone told her they were out of supplies and were unable to order them. She would report to the VP immediately. She said she assumed the role of administrator of the facility on [DATE]. She said they had the former DON at that time. She said the staff never reported to her anything about being out of supplies. She said it was the policy of the facility that the DON ordered the supplies. She said she did not check the cart but was educated on the general aspects of the system. She said they did the ad hop QAPI. She said she was still acclimating to the facility, was relatively new to the building and no one made her aware of any issues. Record review of a facility clinical meeting plan indicated ad hoc QAPI meeting dated [DATE] indicated the medical Director was present via phone, emergency supplies at the bedside, emergency supplies being available, and inspection of the crash cart. During observations on [DATE] at 7:15 a.m. with the VP revealed the crash cart was full stocked with AED pads and two ambu bags, and the crash cart check off list was signed. The DNR list was completed on [DATE] . Record review of the crash cart and check off list on [DATE] at 8:00 a.m. with the VP indicated it had been checked for the appropriate days and the supplies were present. Record review of trainings dated [DATE] indicated education was provided on emergency equipment and a test on what equipment could consist of, when to order, who to notify if the equipment need to be ordered, where the equipment was kept and where ventilator patient supplies were kept. Interviews were conducted with facility staff on [DATE]. At 1:57 p.m. ADON RN At2:23 p.m. LVN H worked 6 to 6 p At 2:39 LVN I worked 6a to 6p At 2:48 p.m. RN J worked 6a to 6p At 3:46 p.m. LVN K worked 6p to 6a At 9:14 p.m. LVN L worked 6p to 6a At 9:25 p.m. LVN B worked 6p to 6a Interviews were conducted with facility staff on [DATE]. At 7:25 a.m. LVN G worked form 6a to 6 p At 7:30 LVN E worked from 6a to 6p. Interviews with nurses indicated they were knowledgeable about the in-services provided regarding CPR and ensuring supplies were on the cart and available. They said if they used emergency supplies, they would replace them, and notify the DON. If they checked the crash cart and supplies were not there, they would not just initial the check list. They would notify the DON, let the Administrator know and if need be, notify the VP of Clinical operations. They were knowledgeable about the black boxes at the bedside of trach residents that contained an extra trach and ambu bag. The nurses said they were not to replace a trach if it became dislodged to call 911 and have the trach for the EMS staff. Record review of a facility clinical meeting plan indicated ad hoc QAIP meeting, dated [DATE], indicated the Medical Director was present via phone, emergency supplies at the bedside, emergency supplies being available, and inspection of the crash cart. Record review of the crash cart and check off list, on [DATE] at 8:00 a.m., with the VP indicated it had been checked for the appropriate days and the supplies were present. Record review of trainings, dated [DATE], indicated education was provided on emergency equipment and a test on what equipment could consist of, when to order, who to notify if the equipment need to be ordered, where the equipment was kept and where ventilator patient supplies were kept. The Administrator and VP of Clinical Operations were informed the IJ was removed on [DATE] at 8:05 a.m.; however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure residents had the right to be fee from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Resident #1 and Resident #2) reviewed for neglect. 1. The facility failed to ensure the former DON was aware AED pads (AED pad are a vital part of the AED machine that are used to help people experiencing sudden cardiac arrest. The AED pads are place on the person's bare chest and are attached to a cable that connects to the AED to the patient body. The AED then analyzes the hearts rhythm and can deliver an electric shock or defibrillation, to help the heart re-establish normal rhythm.) and Ambu bags (a bag value mask- a handheld tool that is used to deliver positive pressure ventilation to a subject with insufficient or ineffective breaths.) were missing for over 10 days and did not secure supplies. 2. The facility failed to ensure the staff responsible for checking the supplies on the crash cart were following the policy and procedures in place, to either replace the supplies or notify administrative staff the supplies were missing. 3. The facility neglected to ensure necessary supplies were available for tracheostomy residents to have tracheostomy and [NAME] bags at the beside. 4. The facility failed to ensure staff were adequately trained on noninvasive respiratory care. 5. The facility failed to have nurse competency training to ensuring staff were proficient in providing care on noninvasive respiratory equipment. 6. The facility neglected to have a system in place to ensure residents needs were met, with supplies, and training of staff. 7. The facility failed to ensure Resident #1 did not go without oxygen to her brain for about 10 minutes until EMS arrived. 8. The facility failed to ensure Resident #2 had an [NAME] bag or trach at his bed side per physician orders. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of serious harm and possible death. Findings include: 1. Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute respiratory failure and morbid obesity. Record review of Resident # 1's baseline care plan, dated [DATE], reflected she was a full code (CPR to be preformed) there was no additional info documented on the form. Record review of Resident #1's care plan, dated [DATE], reflected a Focused area of Full Code. Some of the interventions were the resident would receive CPR if indicated, and to continue CPR until the resident responded or until EMS arrived to take over the code. A Focused area tracheostomy status and was at risk for increased secretions, congestion, respiratory infections, and infections to tracheostomy. She required a trach Bovina (name brand) flex 7 humidification with air compression at 50 PSI OS at 8 liters per minute via trach collar. Some of the interventions were Ambu bag and an extra inner cannula along with 1 size smaller to be kept at the beside. Monitor oxygen stats and apply oxygen as ordered. Monitor for needed suctioning of increased secretions, congestion assessed for relief. Record review of Resident #1's MDS, dated [DATE], titled other was incomplete. Record review of Resident #1's computerized physician orders reflected BiPap/APAP to be worn at night on at night off in the mornings with setting specified. An order for trach bovina flex 7 extra of that size and one size smaller to be kept in supply box at bedside, dated [DATE]. The resident required Foley catheter care every shift. May change disposable inter canula of trach daily, emergency trach supplies were to be kept at bedside to include oxygen source, suction machine, additional trach and ambu bag. Record review of nursing notes, dated [DATE] at 7:57 p.m., reflected Resident #1 arrived at the facility via EMS. The resident was alert and oriented to self, time, place, situation, and able to make her needs known. She was a full code. Her vital signs were within normal limits, and she voiced no pain. Record review of a RT note, dated [DATE] at 3:41 p.m., reflected Resident #1 was placed on a speaking value and trach was suctioned. Suctioned a small amount of thin white secretions. The patient tolerated the treatment well. Nursing staff on duty instructed on how to place the speaking valve. Time spent 25 minutes. Record review of nursing note, dated [DATE] at 3:00 a.m., reflected at 2:15 a.m. CNA called nurse to the room. LVN B went into the room and the resident stated she could not breath and wanted to be switched to her humidified oxygen. LVN B attempted to suction the resident with no secretions removed. The resident went unresponsive with no pulse and no respirations. CPR was started and the crash cart obtained, AE pads applied and 911 called. EMS arrived and CPR continued at 2:32 a.m. pulse obtained but resident continued to be unresponsive, and breaths given via ambu bag continued per EMS instructions. At 2:43 a.m. the resident was transferred to a stretcher, and continued to be unresponsive, pulse continued, continued to administer breaths via ambu bag. At 2:45 a.m. resident transferred to hospital. Note signed by LVN A. Record review of the facility's crash cart check off list [DATE] reflected on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] there were no check offs for those days and the form was not initialed. The rest of the days and the days in between were checked and the form was initialed. Record review of the facility's crash cart check off list for [DATE] reflected there was one day the form was not signed [DATE] all other days were checked as if the supplies were there and signed. Record review of the facility's crash cart check of list for [DATE] reflected on [DATE], [DATE] and [DATE] the slot for ambu bag was circled and checked. All the other dates except [DATE] were checked and initialed. On [DATE] it was not checked or signed. Record review of an EMS report, dated [DATE], reflected they were called at 2:17 a.m. They arrived at the facility at 2:24 a.m. and they were at the patient at 2:25 a.m. The facility staff said Resident #1 had only been at the facility for two days. They reported they were not familiar with her. The staff reported Resident #1 hit her call light and told them she was having breathing problems. The resident had no emergency trach at bedside. All the staff members denied her being their patient and was unable to locate the patient caregiver( LVN A). The staff reported the resident started to turn blue before going into cardiac arrest surrounding 2:15 a.m. The fire department was requested by EMS for lift assistance and possible riders due to the patient, not fitting. The report reflected they arrived at the patient side to find [AGE] year-old female lying in bed with CPR being performed. The patient was pulseless and had her ventilator providing resume breaths. Her face appeared purple and warm and dry skin touch. A rapid assessment was performed and findings were noted on the assessment. The patient was removed from the vent and placed on ambu bag. Staff were informed and squeezed the ambu bag about every six seconds. The patient was applied to monitoring devices via stat pads and found with no heart rate. The staff were struggling when attempted to use the ambu bag on the resident. The staff member used two hands to squeeze. EMS attempted one ventilation switch to replacing the trach. EMS was informed the patient did not have any emergency trach on standby. EMS used the adult [NAME] (a tool used to unclog trach) and forced it past the clotted mucus plug. EMS suctioned the place the resident back on the bag. The [NAME] was covered in thick nasty mucus. The Ambu bag was now easy to squeeze without issue. Staff informed to breathe with ambu bag about every three seconds until she resumed her normal breathes. EMS quickly obtained return of spontaneous circulation (resumed heart rate) and the fire department was called to assist. EMS interventions continued as noted above. Record review of Resident #1 hospital records, dated [DATE], reflected per admitting providers documentation. Resident #1 was a [AGE] year-old female with a history of diabetes, high blood pressure, morbid obesity, tracheostomy and feed tube. She presented to the emergency department via nursing facility care on [DATE] after a cardiorespiratory arrest. Per nursing home staff, the patient complained of shortness of breath and having difficulty breathing and became unresponsive with no pulse. They initiated CPR with an approximated downtime of 10 minutes prior to EMS arrival. EMS gave one round of epinephrine (used to improve breathing and stimulate the heart.) Resident #1's heart rate resumed, and she was transported to the emergency room . In the emergency department she was placed on a mechanical ventilation via trach. She was admitted to the ICU after cardiorespiratory arrest. The patient was not waking up despite no sedation medications provided. On [DATE] the patient remained on mechanical ventilation with the assisted control and possible seizure disorder. On [DATE] and MRI of the brain was completed and indicated acute encephalopathy due to Anoxic (complete absence of oxygen in an organ or tissue) and brain injury. During an interview on [DATE] at 5:10 a.m., LVN B said there was an incident on [DATE] on the night shift when Resident #1 coded while she was talking to her, and she had to preform CPR. She said Resident #1 was on a Trilogy respiratory system. The resident was hooked up to the vent at night and during the day they had humidified air connected to the trach. She said they had two other residents on that noninvasive respiratory system Resident #2 and Resident #3. LVN B said she was trained on the system when she first started work at the facility. She said they did not have a full time RT. The RT came to the facility on ce or twice a week. During an interview on [DATE] at 7:00 a.m., LVN E said on Sunday, [DATE], she worked from 6PM to 12 PM shift. She said she had gone to Resident #1's room around 11:00 p.m. to hook up her vent. She said Resident #1 was making phone calls, and she was on the phone with her husband. LVN E said Resident #1 had asked her to wait until she was finished with her phone call. LVN E said she went back maybe 10 to 15 minutes and completed the transfer of Resident #1 to the vent from one air way flow to the other. LVN E said when she put Resident #1 on the vent, she was fine and when she left, she asked the resident if she needed anything. She said she was not at the facility when the resident coded, she had already left for the night. She said she was trained on the trilogy system when she first stated to work at the facility. During an interview on [DATE] at 7:38 a.m. the VP of Clinical Operations said the Trilogy system was a noninvasive respiratory support system. She said tracheostomy care was invasive they must go down into the trach to suction. The residents who were on the machinery could breathe without being connected to the machine. She said the vent was on at night only, and they come off during the day. She said they used the AVAPs and BiPap procedure. She said they had a cuff with insulated around the trach itself inflated like a donut around the tube. She said it was the same principle as a catheter ball. The VP said they did not do anything with the setting on the machinery. She said the settings were preset prior to admission by the company staff, and they communicated with the doctors at the hospital, prior to bringing the machinery into the facility. She said staff were only to hook the resident up, unhook them, and provide suctioning as needed. She said they did not change the settings and could not change the settings on the device. She said the nurses were usually trained by the RT when they started work. She said prior to her filling in as the DON, there was no official training on record. She said they did not have any type of nursing check offs. The training that the RT provided her on paper was about trach care and not about the Trilogy machine or devices. On the list of nurses who received the training 4 nurses received the training on [DATE] and three received the training on [DATE]. The VP said she scheduled the RT to do some training on [DATE] and [DATE] with return demonstrations and staff competency check offs so she could have something in their files. During a telephone interview on [DATE] at 10:00 a.m., LVN A said Resident #1 was her resident on the morning of [DATE]. She said she had gone to lunch and was gone about 15 minutes. When she arrived back at the facility LVN B and LVN C were performing the code, EMS was already there when she got back. She said they did 3 or 4 rounds of just compressions, EMS got Resident #1 suctioned. The LVN said when EMS suctioned Resident #1 a lot of blood came out. She said EMS connected the ambu bag to the teach. During a telephone interview on [DATE] at 10:45 a.m., LVN A said Resident #1 did not have a trach at her bedside because she did not see one. She said she did not think EMS asked for one. She said CNA D called LVN B to say Resident #1 was having difficulty breathing. LVN B told her when she arrived in room Resident #1 was talking and when she removed the Trilogy from her and tried to suction her Resident #1 coded. She said then they started CPR. During an interview on [DATE] at 11:45 a.m., LVN G said when Resident #1 came from the hospital they did not send any extra supplies. LVN G said she kept a trach on her cart for emergencies. She said the one she had was for Resident #3. During an observation and interview on [DATE] at 11:40 a.m. of the storage room revealed they had the [NAME] brand name size 8 trach, there were two boxes. The VP said they were all size 8's and they came in this weekend. She said prior to her assuming the DON position she was told supplies were on back order. During an interview on [DATE] at 1:22 p.m., the VP of Clinical Operations said she took the position as acting DON on [DATE] and was informed that day the supplies were not on the crash chart. She said she did do an impromptu in-service about the crash cart and supplies. She said she did not conduct a formal in service because she thought the items were used on [DATE], she did not realize they did not have them to use. The VP said she checked the crash cart to make sure it had everything in place and since she took the position. She had found the ambu bags in a box in the storage room. Thy did not have any AED pads. The VP said she ordered them one day and they were delivered the next day. She said staff members told her the former DON said the items were on back order, however she did not have a problem getting them. She said they now had extra everything. During a telephone interview on [DATE] at 1:00 p.m., CNA D said she and CNA F were walking down the hall and Resident #1 started screaming she could not breath. She said LVN B came into the room and tried to fix her oxygen. CNA D said that did not work, and Resident #1 was turning blue. She said LVN B screamed for LVN C to get the crash cart. She said when they got the chart she knew they could not find something but she did not know what it was. During a telephone interview on [DATE] at 1:05 p.m., CNA F said she and CNA D were walking down the hallway on the morning of [DATE] about 2:00 a.m. They heard Resident #1 say she could not breathe. She said LVN B came in and started checking her tubes. She said LVN B began to try to suction Resident #1, and suctioning did not work. She said the resident started turning blue. She said LVN B began CPR and she and LVN C called for the crash cart. CNA F said there were no AED Pads and no Ambu bag. She said when EMS arrived they had those things. She did not know if EMS was looking for anything or not. During a telephone interview on [DATE] at 1:09 p.m., LVN C said she was down the hall and LVN B screamed her name. She said LVN B was in Resident #1's room and she was a new patient. LVN said she knew nothing about the lady. She said when she arrived in the room Resident #1 was turning blue. She said LVN B was starting CPR and they got the crash cart. She said there were a couple of things missing from the cart, the AED Pads and ambu bag. She told the other nurse to call 911. She said EMS was very quick to respond. She said they did not go the storage room to look for an ambu bag or AED pads. She said they spent their time trying to save the residents life. LVN C said Resident #1 was a large woman, it took both to do compressions and try to suction her. She said when EMS arrived, they put the Ambu bag on Resident #1. She said at first the bag was hard to squish it because there was no airflow. She said they were able not to suction her, however, EMS had a tool to remove the mucus plug. She said when the former DON was at the facility, she was informed they did not have ambu bags, AED pads and supplies. She said since the new DON arrived, they have all the supplies. She said she did not know if Resident #1 had an extra trach at the bedside or not. She was on the other side of the bed. She said EMS did ask if Resident #1 was either one of the nurses patients and she was not. She said Resident #1's nurse was on break. She said she did not know if EMS asked for a trach or not, she barely knew Resident #1's name. During an interview on [DATE] at 2:56 p.m., the ADON said she knew sometimes when she was doing treatments. The former DON said she was having a problem getting supplies and some supplies were on back order. The ADON said the ambu bag was supposed to be on the cart and they had some in a box in the supply room. During an interview on [DATE] at 11:10 a.m., LVN I said she started work at the facility on [DATE]. She said on [DATE] she was shadowing LVN A. She said LVN A had left the facility. LVN I said she was in the hallway when LVN B yelled she needed help with CPR. She said she had gone into Resident #1's room and she did not see a trach on her bedside table. LVN I said she did not remember if EMS asked for a trach or not. She said when the crash cart arrived there was no ambu bag or no AED pads. She said the staff were unable to use the AED machine and they did compressions until EMS arrived. She said the resident was probably not breathing for 9 to 10 minutes with no pulse. LVN I said she was in serviced on the trilogy system and trach care but was not comfortable with doing it by herself at the current time. During an interview on [DATE] at 2:04 p.m., the VP said the Trilogy system was not life support. She said residents were able to breath on their own. She said they had red plugs if electricity went out they used the generator. She said she did not know what training the RT had done or what training the manufacture had done. She said they did not have anything written down, and no competency check offs. She said she realized that was a problem and had asked the RT to come and train on [DATE] and [DATE]. She said they needed something in place and they needed to know what staff had what training. The VP said they had nothing when she took the position. She said she did not know why they had the extra trach at the bedside, she did not think the nurses were to replace them. She said she knew with Resident #3 took his trach him when he went to the Pulmonologist. She said they sent the trach with Resident #3 when he went to the hospital in case there were complications. She said the facility nurses never replaced a trach on the inner cannula. During a telephone interview on [DATE] at 2:08 p.m. with the Medical director, he said he was busy and could talk, to talk to the NP. The NP sent a text saying she was busy as well but could answer questions via text. The NP said her expectations of staff was to get vitals every shift, complete trach care each shift and as needed, suction as needed and check on patients every two hours and as needed. The NP said staff should be trained on what to do if the trach got dislodged, how to clean the trach site and do dressing changes. The NP said the noninvasive respiratory system was not life support, the resident received only oxygen during the day. She said if the electricity went they had a generator and the system had a 8 hour battery life. During a telephone interview on [DATE] at 2:15 p.m., the manufacture's Account Executive she said the tracheostomies were invasive and life sustaining she said Resident #2 and Resident #3 had trach and they were invasive life sustain. However, the respiratory system did not classify as life support. She said she talked to her RT to clarify the noninvasive system and was not life support. She said the trilogy system had an 8 hour back up battery. She said the suctioning device was not provided by them. She said she had done some training with the facility nurses, and she could not provide the training information. She said her boss had that information and she was on leave. She did not know how many staff she trained or on what dates. 2. Record review of Resident #2's face sheet reflected he was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Some of his diagnoses included acute respiratory failure and tracheostomy status. Record review of Resident #2's other MDS, dated [DATE], reflected he had severe cognitive impairment. He was totally dependent on staff for ADL assistance. Record review of Resident #2's care plan, dated [DATE], reflected a Focused area of Full Code. Some of the interventions included the resident would receive CPR if indicated, and to continue CPR until the resident responded or until EMS arrived to take over the code. A Focused area tracheostomy status and was risk for respiratory infections, and infections to tracheostomy. He required a trach Shiley (name brand) size 7 humidification with air compression at 55 PSI OS at 8 liters per minute via trach collar. Some of the interventions were monitor for needed suctioning due to increased secretions. Record review of Resident #2's computerized physician orders reflected BiPap/APAP to be worn at night on at night off in the mornings with setting specified. Order for trach information 8 extra of that size and one size smaller to be kept in supply box at bedside, dated [DATE]. Foley catheter care every shift. May change disposable inter canula of trach daily, emergency trach supplies were to be kept at the bedside to include oxygen source, suction machine, additional trach and ambu bag. During an observation of Resident #2's room on [DATE] at 11:45 revealed no trach in the room at his bed side. During an interview on [DATE] at 11:00 a.m., RN J said she started working at the facility on [DATE]. She said when she arrived at the facility today, [DATE], Resident #2's oxygen stats were low. He had orders to switch from the vent to a regular humidifier. She put on 8 liters of oxygen and did not work, his oxygen stats continued to drop. He also had a temperature of 103. She said he had a lot of secretions, and the NP was contacted and said to send him out. The RN said she was trained a little bit on the noninvasive Trilogy system. She said she was not comfortable providing care to Resident #2 and needed more training. She said she went to get a nurse from another hall to assist her with Resident #2's care. During an interview on [DATE] at 11:05 a.m., LVN H said she had worked at the facility for approximately 9 days. She said she had some training on the Trilogy system when she stated, however, she worked with tracheostomy before starting to work at the facility. She said she was provided information on the basic care for trach but was not given any type of skills check off. She said RN J asked her to come and assist her with the Resident #2 care this morning. She showed her how to suction the resident, but he did not handle that well. She said Resident #2's oxygen stats dropped and on further assessment he had a fever. She said the machine had beeped early saying low pressure alarm, and they sent him to the hospital this morning. Record review of the facility's tracheostomy care policy, dated [DATE], reflected the facility would ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person, centered, care, plan, and residence goes in preferences. The facility will ensure staff responsible for providing tracheostomy care, including suctioning or trained, and competent, according to professional standards of practice. Record review of the facility's policy on tracheostomy care/suctioning, dated [DATE], reflected the facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care, consistent with professional standards, and practice, the comprehensive person, centered, care, plan, and resident goes and practice preferences. The tracheal secretion was performed by licensed nurse to clear the throat and upper respiratory track of secretions that may block the airway. Record review of the facility's noninvasive ventilation policy, last updated [DATE], reflected it is the policy of the facility to provide non-invasive ventilation as per physician, orders, and current standards of practice. AVAP or average volume assured pressure support was a modality of non-invasive ventilation that integrates the characteristics of both volume and pressure controlled, non-invasive ventilation and delivered a fixed digital volume via tracheotomy or a mask that fits over the nose, and or Mouth. A BiPAP or bi-level positive airway pressure was a similar respiratory therapy intervention that delivered an inhale pressure and an excel pressure to provide a patient airway. It required a machine that generated the separate pressures through a two via tracheostomy or a mass that fits over the nose and or mouth. The policy explanation and compliance guidelines. Noninvasive ventilation systems such as CPAP,VPAP, and BiPap and trilogy vary by manufactures common equipment includes the machine tubing mask, headgear straps, dislodge non-disposable filters and humidifier chamber. The facility will obtain an order for the use of a CPAP BiPAP, AVAP or trilogy and settings from the practitioner. Settings will be maintained by the company and the respiratory therapist. The facility will follow manufacture instructions for use of the machine. The facility will assess the integrity around the mask side to ensure there is no impairments to the skin. And document use of the machine, the resident's tolerance, any skin, respiratory or any other changes and response. Follow manufacture instructions for the frequency of cleaning replacing filters and servicing machine. Only the supplier may service the machine. Record review of the facility's, abuse, neglect, and exportation policy, dated [DATE], reflected it is the policy of the facility to provide protections for health, welfare, and rights of each resident by developing, and implementing written policies and procedures that prohibit and prevent abuse, and neglect. Neglect was defined as a fear of the facility, is employees, or service providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish, or emotional distress of abuse. The policy indicated, assuring and assessment of resources needed to provide care. Period. And identification is possible of abuse include, but not limited failure to provide care needs This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:00 PM. The Administrator and VP of Clinical Operations were notified and was provided with the IJ template on [DATE] at 4:05 p.m The following Plan of Removal submitted by the facility was accepted on [DATE] at 1:22 p.m.: Problem: F600 Neglect. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. All nurses will be educated on respiratory therapy for nurses, including but not limited to tracheostomy care, Trilogy care, Tracheostomy suctioning, by the respiratory therapist. Approaches: The VP of Clinical Operations, Clinical Support Specialist, respiratory therapist and ADON will deliver in service education to nurses one on one. If emergency items are on back order from the supplier, the facility is able to obtain said supplies from many of our sister facilities. The Director of Nursing, Administrator, ADON, and Treatment Nurse were educated by the VP of Clinical Operations, to notify the VPCO immediately if emergency supplies are back order and are needed by the facility immediately. This in-service was completed on [DATE].The VPCO will ensure supplies are obtained from a sister facility. 1. The facility medical Director was informed of the IJ on [DATE] by the VP of Clinical Operations. 2. Resident #1 remains in the hospital. 3. Ambu bags, AED, AED Pads, and extra emergency tracheostomy cannulas are available in the facility and on the crash cart, verified by the VP of Clinical Operations on [DATE]. 4. Resident #2 has emergency Ambu bag, emergency tracheostomy cannula in a designated red and black tool box, labeled Ambu bag and extra trach, at the bedside, placed by the VP of Clinical Operations on [DATE]. 5. Each resident in house with a tracheostomy has the emergency box with supplies at the bedside, placed by the VP of Clinical Operations on [DATE]. 6. There are extra emergency Ambu bag toolboxes in the medication room for future residents with tracheostomy's, to be utilized on admission to facility. Nurses were in serviced by the VP of Clinical Operations on [DATE] regarding the new emergency toolboxes. All nurses will be in serviced on this new system before they are able to return to facility for their shift. All new nurses will be trained on this practice prior to starting their shift on the floor. This training will be placed in the clinical orientation packet with HR by the VP of Clinical Operations on [DATE]. 7. All nurses were in-serviced by the VP of Clinical Operations regarding checking the crash cart every night to ensure all items are present on the crash cart according to the emergency crash cart checklist, and any items missing from the crash cart, to notify the DON immediately, so the items can be replaced on the crash cart. The 100-hall nurse is designated to check the crash cart every night, this is included on the in-service given to nursing staff by the VP of Clinical Operations on [DATE]. Also included on the in-service was for the nurses to leave any items that are missing from the crash cart, unchecked on the crash cart log. This in-service was completed on [DATE] by the VP of Clinical Operations. All nurses will be in-serviced on this system prior to returning to their shift. All new nurses will be trained on this practice prior to beginning their shift. This information is added to the clinical orientation with HR on [DATE] by the VP of Clinical Operations. 8. All nurses will be educated on the Crash Cart policy and policy for ensuring emergency equipment for tracheostomy residents including Ambu bag and emergency trach are at the bedside of tracheostomy residents. All nurses on staff at this time besides one that is in the hospital, h [TRUNCATED]

Based on interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 Residents (Resident #1) reviewed for pressure injuries. The facility failed to prevent deterioration for Resident #1 of MASD of bilateral buttock to a necrotic unstageable pressure ulcer. The facility failed to ensure wound care was provided twice a day as ordered to Resident #1's MASD of the bilateral buttocks to prevent deterioration. Resident #1 did not receive 6 of 10 wound care treatments to his bilateral buttocks. The facility failed to follow their policy by not assessing Resident #1's deteriorating wound. The facility failed to have a system in place to ensure treatments and assessments were being performed per orders and policy. This failure resulted in an identification of an Immediate Jeopardy (IJ) On 5/31/24 at 3:30 p.m. While the IJ was removed on 6/01/24, the facility remained out of compliance with a scope identified at a pattern and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1. Record review of the face sheet dated 6/4/24 indicated Resident #1 was an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, hypertension (elevated blood pressure), and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 required substantial/maximum assistance with toileting hygiene, showering/bathing, rolling to the left and right, moving from sitting to lying, and moving from lying to sitting on the side of the bed. The MDS indicated Resident #1 was dependent with transfers. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #1 had 1 stage 3 (full thickness tissue loss. Subcutaneous fat may be visible, but bones, tendon, or muscle is not exposed. Slough (any yellowish material noted in the wound bed) may be present but does not obscure the depth of tissue loss) pressure ulcer and 2 unstageable pressure ulcers. The MDS indicated the 1 stage 3 pressure ulcer, and 2 unstageable pressure ulcers were present upon admission to the facility. Record review of the care plan last revised on 5/23/24 indicated Resident #1 had a potential risk for impairment to skin integrity related to fragile skin and decreased mobility with interventions including monitor/document location, size, and treatment of skin injury and report abnormalities, failure to heal, signs and symptoms of infection, maceration (a softening and breaking down of the skin resulting from prolonged exposure to moisture), etc. to the physician. The care plan indicated Resident #1 required a foley catheter (type of urinary catheter). Record review of the physician orders dated 6/4/24 indicated Resident #1 had an order to clean bilateral buttocks with normal saline or wound cleanser then apply barrier cream every shift for MASD starting 5/23/24. The physician orders indicated Resident #1 had an order to cleanse the open area to the sacrum with normal saline or wound cleanser, apply collagen, and cover with a dry dressing starting 5/29/24. The physician orders indicated Resident #1 had an order to cleanse open area to the sacrum with normal saline or wound cleanser, apply calcium alginate (a highly absorptive dressing composed of calcium sodium alginate that creates a comfortable protective gel when in contact with drainage and helps maintain a moist wound environment), and cover with dry dressing every day shift starting 5/30/24. Record review of the TAR for May 2024 indicated Resident #1 was scheduled to have wound care to his bilateral buttocks as ordered during the day shift on 5/24/24, 5/25/24, 5/26/24, 5/27/24, and 5/28/24 and during the night shift on 5/23/24, 5/24/24, 5/25/24, 5/26/24, and 5/27/24. The TAR indicated Resident #1 did not have wound care performed to his bilateral buttocks on the day shift on 5/26/24 and on the night shift on 5/23/24, 5/24/24, 5/25/24, 5/26/24, and 5/27/24. The TAR indicated Resident #1 was scheduled to have wound care performed to the open area to his sacrum on 5/29/24 and 5/30/24. The TAR indicated he did not have wound care performed to the open area to his sacrum on 5/29/24. Record review of the skin assessment dated [DATE] indicated Resident #1 had discoloration to his buttocks. The skin assessment indicated Resident #1's buttocks previously had fragile scar tissue now with purple discoloration and some noted partial thickness (wounds that extend into the first two layers of skin) opening. Record review of the skin assessment dated [DATE] indicated Resident #1 had MASD to his buttocks. The skin assessment indicated Resident #1 had treatments in place to his wounds. The skin assessment indicated Resident #1 had a low air loss mattress (mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown). The skin assessment indicated Resident #1 had frequent loose bowel movements (bowel movements that may be watery, mushy, or shapeless). The skin assessment indicated Resident #1 was unaware of bowel movements. Record review of the Wound assessment dated [DATE] indicated Resident #1 had MASD to the sacrum starting 5/20/24 measuring 9cm x 5cm with partial thickness scattered 0.1cm. Record review of a nursing progress note dated 5/23/24 indicated upon getting Resident #1 ready for an appointment it was noted he had MASD with open areas to his bilateral buttocks. The progress note indicated the area was cleansed and the progress note indicated a new order was obtained for barrier cream to the bilateral buttocks for MASD and to cover with a dressing as needed. Record review of the Wound assessment dated [DATE] indicated Resident #1 had a pressure ulcer to his sacrum that was reclassified from MASD to unstageable (type of pressure ulcer that is unstageable due to being covered by necrotic tissue and occurs when prolonged pressure on the skin prevents blood flow and oxygen from reaching the tissue). The Wound Assessment indicated the pressure ulcer to Resident #1's sacrum measured 11cm x 10cm x 0.1cm. The Wound Assessment indicated contributing factors to Resident #1's pressure ulcer included immobility, increased bowel incontinence, diabetes, hospitalization , and worsening since re-admission. Record review of the progress note from the wound care physician dated 5/30/24 indicated Resident #1 had an unstageable (due to necrosis) full thickness pressure ulcer to his sacrum measuring 11cm x 10cm x 0.1cm with 40% slough in the wound bed. The progress note indicated the wound care physician recommended to off load the wound by turning side to side in the bed every 1-2 hours, limit sitting to 60 minutes, and utilizing a low air loss mattress. During an interview on 5/31/24 at 12:02 p.m. Resident #1 was needing something for his bottom. said he had a wound on his bottom, and it hurt. Resident #1 said he had a round cushion to sit on but still need something to aid with the pain. Resident #1 said he was being seen by the wound care doctor, but his wound was not getting any better. Resident #1 said the facility staff were treating his wound, but he did not know how often. During an interview on 5/31/24 at 1:02 p.m. the Wound Care Doctor said when Resident #1 came out of the hospital, he had MASD to his bilateral buttocks that was not over a bony prominence. The Wound Care Doctor said the wound now covered both Resident #1's buttocks and the sacrum. The Wound Care Doctor said the wound was necrotic and had slough in the wound bed. The Wound Care doctor said several factors could have contributed to the deterioration of Resident's #1's wound including incontinent care not being performed in a timely manner, lack of turning and repositioning, and decreased nutrition. The Wound Care Doctor said he originally ordered wound care for the MASD twice a day due to the amount of drainage the MASD to Resident #1's wound had. The Wound Care Doctor was not aware wound care for Resident #1 had not been performed to the MASD on the day shift of 5/24/24 or on the nights shifts of 5/23/24 through 5/27/24. The Wound Care Doctor said he could not say for sure if the lack of wound care had contributed to the deterioration to the bilateral buttocks and sacrum. The Wound Care Doctor said if the drainage had subsided once daily may have been sufficient. The Wound Care Doctor did say he expected his orders to be followed and when the order was written for twice daily it was due to drainage and to prevent deterioration of the wounds. Record review of the facility's Documentation of Wound Treatments dated 7/2022 indicated, The facility completes accurate documentation of wound assessment and treatments, including response to treatment, change in condition, and changes in treatment. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact). Additional documentation shall include but is not limited to: a. Date and time of wound management treatments. b. Weekly progress towards healing and effectiveness of current intervention. c. Any treatment for pain, if present. d. Modifications of treatment or interventions. e. Notifications to physician and/or responsible part regarding wound or treatment changes. This was determined to be an Immediate Jeopardy (IJ) on 5/31/24 at 3:43 p.m. The Administrator was notified. The Administrator was provided with the Immediate Jeopardy template on 5/31/24 at 3:48 p.m. The following Plan of Removal submitted by the facility was accepted on 6/1/24 at 11:36 a.m. and included: 1. Immediate actions The Medical Director (Resident #1's Primary Care Physician) was notified by the Director of Nursing on 05/31/2024 of the Immediate Jeopardy. A full skin sweep was completed on all residents on 05/31/24 by the Wound Care Nurse and the Director of Nursing. There were no further negative findings with the full facility skin sweep. The Director of Nursing verified that Resident #1's wound care was performed and documented. Resident #1's RP and provider were notified by the Director of Nurses, of the negative findings. All residents were reviewed to ensure head-to-toe skin and wound assessments were completed appropriately, by the Director of Nurses and Wound Care Nurse. 2. Education (provided by the DON, the ADON or Designee) The VP of Clinical Services in-serviced the Director of Nursing and Wound Care Nurse on all of the below in-services on 05/31/2024. All nurses were in-serviced by the Director of Nursing on appropriately completing skin assessments and notifying the provider of all newly identified skin issues in a timely manner on 05/31/2024. Each nurse will be in-serviced prior to returning to shift. This will be completed by 06/01/2024 and nurses will not return to shift without the in-service. The Director of Nursing and the Wound Care Nurse were responsible for ensuring each nurse completed their skin assessments and wound treatments. The Director of Nurses and/or the Wound Care Nurse will monitor the omissions report for wound care, prior to leaving their shifts for the day. Wound care will be assigned to another nurse by the DON or designee, if the attending nurse was not able to complete wound care for their shift. In the electronic healthcare system, there was a reports selection to monitor if there were any omissions in the ETAR's and EMAR's. The Director of Nursing or designee can access the EMARs and ETARs through the software system as well. Schedules were auto created through the Electronic Medical Record system. Nursing staff were in-serviced by the Director of Nursing on 05/31/2024, to notify the Director of Nurses before the end of their shift if they were not able to complete their wound care treatments. This must be communicated in the electronic health reporting system so there was documentation of this being performed. The VPCO, the Administrator, the DON, the ADON, and the Wound Care Nurse monitor the system constantly throughout the entire 24-hour period. The VPCO, the Administrator, the DON, and the Wound Care Nurse will ensure any entries in the system were addressed and all wound care was completed or reassigned to another nurse if needed. The Director of Nursing in-serviced nursing staff on 05/31/24, to complete an audit of their EMARs and ETAR's with the oncoming nurse to ensure there were no omissions in the EMAR's and ETARs for their shift. Each nurse will sign off that they agree there were no omissions. The signature sheet will be reviewed by the Director of Nurses, daily for the next 90 days. The Wound Care Nurse and the DON were re-trained on how to pull the omissions report and directed to check it daily during am clinical meeting, to ensure no treatments were missed going forward, by the VP of Clinical Operations on 5/31/24. If omissions were noted on the report, the nurse responsible for the omission would be contacted immediately by the Director of Nurses or designee to complete documentation related to the omission. The director of Nursing was educated on this process by the VP of Clinical Operations on 05/31/24. All nurses were in-serviced by the Director of Nursing on Policy and Procedure for Pressure Injury Prevention and Skin and Wound Care Management on 05/31/24. This in-service will be completed by 06/01/2024 and nurses will not return to shift without the in-service. This in-service included appropriately completing skin assessments, information on pressure and injury prevention, treatment for non-pressure injuries, accurate documentation of treatments provided, and the importance of wound care management and following the treatment orders. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting will be completed on 06/01/2024. On 6/1/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on 06/01/24 from 6:57 p.m. through 10:03 p.m. including the following: Record review of the Skin Sweep Audit Sheet dated 05/31/24 listed all residents' names and highlighted yellow indicated completed and verified skin assessments dated 05/31/24 were documented for all 84 residents. Record review of a QAPI committee signature sheet dated 05/31/24 indicated a meeting was held regarding treatment/services to prevent/heal pressure ulcers. Record review of Resident #1's five-page Treatment Administration Record (TAR) from 5/1/24 to 5/31/24 indicated that the DON and the Wound Nurse reviewed the TAR. Record review of in-services dated 05/31/24 indicated the DON, Wound Care Nurse, and nurses were trained on completing skin assessments and wound treatment, notifying the provider of all newly identified skin issues in a timely manner, pressure injury prevention and management, audit from shift to shift to verify EMAR and ETAR are complete with the off going and oncoming nurse with signature sheet, nurses to notify the DON if unable to complete treatments as ordered on their shift, all documentation on MAR and TAR should be completed prior to leaving shift, pulling omissions report daily, monitor the report, and address any omissions before the end of the day, pressure injury prevention, treatment for pressure and non-pressure injuries, importance of wound care management and following treatment orders, if Wound Care Nurse was unable to complete treatments or skin assessments, and the DON or designee would assign duties to another nurse and ensure duties were completed. During interviews with the DON and Wound Care Nurse, they said they completed a skin sweep on 05/31/24 and all residents had skin assessments completed. They said Resident #1's wound care was completed and documented as completed. They said they were in-serviced regarding completing skin assessments and notifying the provider of all newly identified skin issues in a timely manner. They said they were responsible for ensuring nurses completed skin assessments and wound care treatments. They said they were in-serviced on monitoring the omissions report for wound care in the electronic healthcare system. They said the Wound Care Nurse would complete all treatments and skin assessments and on the days the Wound Nurse was not available, treatments and skin assessments would be delegated to another nurse. They said an audit of the EMAR and ETAR would be completed with the off going and oncoming nurse to ensure there were no omissions for the shift and each nurse would sign off that they agree there were no omissions. The DON said nurses would use barrier creams during patient care on residents with wounds and CNAs would use barrier creams on all other incontinent residents. They said they were in-serviced on appropriately completing skin assessments, pressure injury prevention, treatment for pressure and non-pressure injuries, accurate documentation of treatments provided, and the importance of wound care management and following treatment orders. The Wound Care Nurse said on Thursdays, wound assessment profiles were scheduled on all Big Wounds (anything Wound doctor sees) and Wound Doctor visits/made rounds. She said 100 Hall skin checks were scheduled on Mondays, 200 hall skin checks were scheduled on Tuesday, 300 hall skin checks were scheduled on Wednesday, and 400 hall skin checks were scheduled on Friday. During interviews with the Administrator, DON, and Wound Care Nurse, they said nurses were in-serviced on completing skin assessments and notifying the provider of any new skin issues identified in a timely manner. During an observation on 6/1/24 at 9:55 p.m. LVN B was able to demonstrate using the facility's computer on the 100 Hall nurse cart how to complete an audit of their EMARs and ETARs. Observed and verified the staff signature sheets located in the narcotic notebook the oncoming nurse and the off going nurse at each shift change used to verify that there was nothing in red on the previous shift prior to taking the shift assignment. During an observation on 6/1/24 at 9:58 p.m., the DON and the Wound Care Nurse were able to demonstrate on facility computer how to pull the omissions report. During interviews with LVN B (DOH 04/30/24, worked 6:00 p.m. to 6:00 a.m. and 2:00 p.m. to 6:00 a.m.), LVN C (DOH - December 2023, worked 6:00 a.m. to 6:00 p.m. and 6:00 a.m. to 12:00 a.m.), and LVN D (DOH - April 2024, worked 6:00 p.m. to 6:00 a.m.), said they were in-serviced on completing skin assessments and notifying the provider of any new skin issues timely. They said the Wound Care Nurse was responsible for completing treatments and skin assessments and if the Wound Nurse was not available, treatments and skin assessments would be delegated to another nurse. They said they were in-serviced on notifying the DON and documenting in the electronic record if they were not able to complete an assigned skin assessment or treatment during their shift. They said they would notify the DON before the end of their shift if they were unable to complete a skin assessment or treatment. They said they were in-serviced on the importance of wound care and following treatment orders, pressure injury prevention, treatment for non-pressure injuries, accurate documenting of treatments provided, and completing skin assessments. They said the DON in-serviced on auditing the EMAR and ETAR with the off going and oncoming nurse to verify there were no omissions in the EMAR or ETAR during the shift. On 6/1/24 at 10:03 p.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as pattern and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition / a need to alter treatment significantly for 1 (Resident #1) of 6 residents reviewed for a change of condition. The facility failed to notify the physician when Resident #1 refused all oral medications for 4 days ([1/18/24 to 1/21/24], which included Furosemide, Isosorbide Mononitrate ER, Carvedilol, Sacubitril-Valsartan [medications used in the treatment of heart failure] and Metformin HCl [ used to treat diabetes]) leading up to his hospitalization on [DATE] during which he was diagnosed with urosepsis. The facility failed to notify the physician when Resident #1 refused to have ordered labs (CBC, CMP and UA) obtained on 1/17/24, which would have identified an urinary tract infection. The facility failed to notify the physician when Resident #1 had decreased oral intake 3 days leading up to his hospitalization (dehydration contributes to bacterial growth). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 4/12/24 at 5:12 p.m. While the IJ was removed on 4/13/24, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of the face sheet for Resident #1 dated 3/28/24 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including, aftercare following joint replacement surgery, fracture of the right femur (the head of the hip joint), acute bronchitis, bradycardia (slow heart rate), dementia, sick sinus syndrome (disease in which the heart's natural pacemaker becomes damaged and is no longer able to generate normal heartbeats at the normal rate) presence of a cardiac pacemaker, insulin dependent diabetes with chronic kidney disease, and high blood pressure. Record review of Resident #1's MDS dated [DATE] indicated he usually understood others and usually made himself understood. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 6). The MDS indicated he had no behavior of rejecting care. The MDS indicated he had no physical (hitting, kicking pushing etc.) or verbal behaviors (threatening others, screaming at others cursing at others). The MDS indicated Resident #1 was dependent on staff for lower body dressing and the putting on/taking off of footwear. The MDS indicated Resident #1 required moderate assistance with upper body dressing, showering, and toileting. The MDS indicated he required supervision or touch assistance with personal hygiene and eating. The MDS indicated he required set up or clean up assistance only with eating. The MDS indicated Resident #1 was dependent on staff for sit to stand transfers, chair/bed- to- chair transfers, toilet transfers, and tub/shower transfers. The MDS indicated Resident #1 required substantial/maximal assistance with walking ten feet, and the ability to move from lying on the back to sitting on the side of the bed with no back support. The MDS indicated Resident #1 required supervision or touch assistance with the ability to roll to the left or right side while in the bed and the ability to move from setting on the side of the bed to lying flat on the bed. The MDS indicated Resident #1 was occasionally incontinent of bladder and was always incontinent of bowel. Record review of the baseline care plan dated 12/22/23 for Resident #1 did not indicate Resident #1 had a catheter. The baseline care plan did not indicate Resident #1 refused care, treatment, or medications. Record review of the comprehensive care plan dated 1/5/24 for Resident #1 did not indicate Resident #1 had a catheter. The baseline care plan did not indicate Resident #1 refused care, treatment, or medications. Record review of the physician order summary report from 12/21/23 to 1/22/24 reflected Resident #1's medication and supplement orders included the following (theis medication orders were active prior to Resident #1's discharge from the facility on 1/22/24); *Aspirin Oral Tablet Delayed Release 81 MG- Give 1 tablet by mouth one time a day for Heart health (start date 12/22/23); *Atorvastatin Calcium Oral Tablet 40 MG -Give 1 tablet by mouth at bedtime for hyperlipidemia (start date 12/21/23); *Furosemide Oral Tablet 20 MG -Give 1 tablet by mouth one time a day for Heart failure (start date 12/22/23); *Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 MG-Give 1 tablet by mouth one time a day for Heart failure (start date 12/22/23); *Spironolactone Oral Tablet 25 MG -Give 0.5 tablet by mouth one time a day for Heart failure (start date 12/22/23); *Carvedilol Oral Tablet 12.5 MG -Give 1 tablet by mouth two times a day for Heart failure (start date 12/21/23); *Metformin HCl Oral Tablet 500 MG- Give 2 tablet by mouth two times a day for DM (diabetes) (start date 12/21/23) *Sacubitril-Valsartan Oral Tablet 24-26 MG -Give 1 tablet by mouth two times a day for Heart failure (start date 12/21/23) *Calcium Carb-Cholecalciferol Oral Tablet 600-10 MG-MCG-Give 1 tablet by mouth one time a day for Supplement (start date 12/22/23) *Ferrous Gluconate Oral Tablet 324 MG -Give 1 tablet by mouth one time a day for anemia (start date 12/22/23); *Fish Oil Oral Capsule 1000 MG Give 2 capsule by mouth one time a day for supplement (start date 12/22/23); *Multi Vitamin/Minerals Tablet -Give 1 tablet by mouth one time a day for Dietary/Nutritional Supplement for 60 Days (start date 1/13/24); *Zinc Sulfate Tablet 220 MG- Give 1 tablet by mouth one time a day for Nutritional/Dietary Supplement for 60 Days (start date 1/13/24); *Prostat two times a day for Wound healing for 60 Days -Give 30 ml by mouth two times a day (start date 1/12/24); and *Vitamin C Tablet 500 MG -Give 1 tablet by mouth two times a day for Nutritional/Dietary Supplement for 60 Days (start date 1/12/24). Record review of the physician's order summary report from 12/21/23 to 1/22/24 reflected Resident #1 was to have a CBC (A complete blood count, also known as a full blood count, is a set of medical laboratory tests that provide information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cells and platelets, the concentration of hemoglobin, and the hematocrit), CMP ( a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working), and UA (urinalysis is a test of your urine. Doctors use urine tests to find issues including UTI)/CS (culture and sensitivity- a culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) one time only related to cystitis (inflammation if the urinary bladder). The order was dated 1/13/24. Record review of the January 2024 MAR for Resident #1 for January 2024 indicated Resident #1 refused the following medications and supplements on the following dates/ times; *Aspirin Oral Tablet Delayed Release 81 MG refused on, 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m., 1/20/24 at 7:30 a.m., and 1/21/24 at 7:30 a.m.; *Atorvastatin Calcium Oral Tablet 40 MG- refused on, 1/19/24 at 7:00 p.m., 1/20/24 at 7:00 p.m., and 1/21/24 at 7:00 p.m.; *Furosemide Oral Tablet 20 MG refused on, 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m., 1/20/24 at 7:30 a.m., and 1/21/24 at 7:30 a.m.; *Isosorbide Mononitrate ER Oral Tablet Extended Release refused on, 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m., 1/20/24 at 7:30 a.m., and 1/21/24 at 7:30 a.m.; *Spironolactone Oral Tablet 25 MG refused on, 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m., 1/20/24 at 7:30 a.m., and 1/21/24 at 7:30 a.m.; *Carvedilol Oral Tablet 12.5 MG refused on, 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m. and 7:30 p.m., 1/20/24 at 7:30 a.m. and 7:30 p.m., and 1/21/24 at 7:30 a.m. and 7:30 p.m. ; *Metformin HCl Oral Tablet 500 MG refused on, 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m. and 5:00 p.m., 1/20/24 at 7:30 a.m. and 5:00 p.m., and 1/21/24 at 7:30 a.m. and 5:00 p.m.; *Sacubitril-Valsartan Oral Tablet 24-26 MG refused on, 1/18/24 at 9:00 a.m., 1/19/24 at 9:00 a.m. and 5:00 p.m., 1/20/24 at 9:00 a.m. and 5:00 p.m., and 1/21/24 at 9:00 a.m. and 5:00 p.m.; *Calcium Carb-Cholecalciferol Oral Tablet 600-10 MG-MCG refused on, 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m., 1/20/24 at 7:30 a.m., and 1/21/24 at 7:30 a.m.; *Ferrous Gluconate Oral Tablet 324 mg refused on, -- 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m., 1/20/24 at 7:30 a.m., and 1/21/24 at 7:30 a.m.; *Fish Oil Oral Capsule 1000 MG refused on, - 1/18/24 at 7:30 a.m., 1/19/24 at 7:30 a.m., 1/20/24 at 7:30 a.m., and 1/21/24 at 7:30 a.m.; *Multi Vitamin/Minerals Tablet refused on, 1/18/24 at 7:00 a.m., 1/19/24 at 7:00 a.m., 1/20/24 at 7:00 a.m., and 1/21/24 at 7:00 a.m.; *Zinc Sulfate Tablet 220mg refused on, 1/18/24 at 7:00 a.m., 1/19/24 at 7:00 a.m., 1/20/24 at 7:00 a.m., and 1/21/24 at 7:00 a.m.; *Prostat refused on, 1/18/24 at 7:00 a.m., 1/19/24 at 7:00 a.m. and 5:00 p.m., 1/20/24 at 7:00 a.m. and 5:00 p.m., and 1/21/24 at 7:00 a.m. and 5:00 p.m.; *Vitamin C Tablet 500 MG refused on, 1/18/24 at 7:00 a.m., 1/19/24 at 7:00 a.m. and 5:00 p.m., 1/20/24 at 7:00 a.m. and 5:00 p.m., and 1/21/24 at 7:00 a.m. and 5:00 p.m. Record review lab sheet dated 1/17/24 indicated Resident #1 had refused to have the CBC, CMP and UA/CS collected that were ordered on 1/13/24. Record review of the nursing progress notes from 1/13/24 to 1/21/24 for Resident #1 did not document reflect the Physician or Nurse Practitioner had been notified of any of Resident #1's oral medication/supplement refusals or that Resident #1 had refused to have the ordered labs (CBC, CMP and UA/CS) collected. Record review of the facility assignment sheets from 1/18/24 to 1/22/24 indicated LVN A took care of Resident #1 on 1/18/24 from 6am-6pm and MA H passed medications to Resident #1 on 1/18/24. The facility assignment sheets indicated MA G was assigned to Resident #1 on 1/19/24 -1/21/24. The assignment sheets indicated LVN I took care of Resident #1 on 1/19/24 from 6am -6pm. The assignment sheets indicated LVN D had taken care of Resident #1 from 6am-6pm on 1/20/24-1/22/24. The facility assignment sheets indicated CNA K took care of Resident #1 from 6a-6p on 1/19/24 and 1/21/24. The facility assignment sheets indicated CNA J took care of Resident #1 on 1/20/24. During an interview on 4/9/24 at 3:50 p.m., CNA K said she could not recall Resident #1. CNA K said she could not remember if Resident #1 had decreased intake (what is consumed orally, what is eaten and drank). CNA K said if any Resident had a decrease in their food or fluid intake she would notify the nurse caring for that Resident. CNA K said any record of Resident #1's intake and output (that which is produced, ejected, or expelled [urine, vomit, stool]) would be documented in the EMR. During an interview on 4/9/24 at 3:54 p.m., CNA J said she remembered Resident #1 and took care of him regularly during his most recent stay at the facility (12/21/23 to 1/22/24). CNA J said Resident #1 had good days and bad days in regard to his oral intake. CNA J said towards the end of his stay it did seem Resident #1 had declined. CNA J said she could not say that his oral intake had decreased substantially but would have notified the nurse caring for Resident #1 if she had noticed a decrease in his intake CNA J said any record of Resident #1's intake and output would be documented in the EMR. During an interview on 4/10/24 at 3:00 p.m., LVN I said she could not remember if she had been told Resident #1 had refused to take any medications. LVN I said she did not think it (Resident #1 refusing oral meds) had been reported to her because she would always go and attempt the administration herself if a MA reported a resident was refusing. LVN I said if a Resident still refused medication during her attempt she would notify the Physician or Nurse Practitioner. LVN I said she could not recall making an attempt to administer Resident #1 medications, thus she believed she had not been notified but could not say for sure. LVN I said she could not remember if Resident #1 had decreased intake leading up to 1/22/24. LVN I said she would have notified the Physician or Nurse Practitioner if she had been notified and had unsuccessfully attempted to increase Resident #1's intake. LVN I said she could not recall if any CNA had reported to her that Resident #1 had decreased intake. LVN I said she could not recall if the independent lab company had notified her that Resident #1 had refused to labs obtained on 1/17/24. LVN I said the Physician or Nurse Practitioner should have been notified of Resident #1's refusal for lab collection. During an interview on 4/10/24 at 3:15 pm, MA G said Resident #1 was refusing all his oral medications leading up to his hospitalization on [DATE]. MA G said she notified the nurse with each pass that Resident #1 was refusing to take his medications. MA G said she would not have waited for him (Resident #1) to refuse all day before notifying the nurse because missing medications could be very serious depending on the medication and purpose of the medication. MA G said the nurse was notified promptly with each refusal as the nurse would need to attempt the administration themself and notify the physician accordingly. MA G could not recall which nurse she notified or the specific dates she cared for him when he was refusing all his oral medications. During an interview on 4/10/24 at 3:29 p.m., LVN D said that it had been reported to him before his shift on 1/22/24 was that Resident #1 had decreased intake over the past 3 days and had no input in the past 24 hours. LVN D was asked to clarify his statement as his note written on 1/22/24 stated Resident has not eaten or had any fluids x3 days. LVN D said that was a mistake., he said Resident #1 had no intake x3 meals (in the past 24 hours) and a decrease in intake in the days leading up to 1/22/24, based on what had been reported to him. LVN D said he had been told by the MAs that Resident #1 had refused some of his oral medications in the days leading up (1/20/24 and 1/21/24) to his hospitalization on [DATE] but was not aware that he (Resident #1) was refusing all of his oral medications. LVN D said he could not recall what medications the MAs said Resident #1 had refused. LVN D said he had not reported to the physician or nurse practitioner Resident #1 was refusing medications and having decreased oral intake prior to 1/22/24 because he had been told that was normal behavior for Resident #1. LVN D explained he had not regularly taken care of Resident #1. During an interview on 4/11/24 at 2:00 p.m., DON Q said she had contacted the lab in order to see if there were any further documents related to Resident #1's ordered labs on 1/13/24, but the lab was not able to provide any additional documents related to the labs ordered on 1/13/24. The DON said the Physician and/or Nurse Practitioner should have been notified that the labs ordered on 1/13/24 had been refused by Resident #1. The DON said it was not acceptable to fail to notify the medical provider that a resident had been refusing oral medications for four days. The DON said the medical provider should have been notified with each refusal. The DON said it was not acceptable for the physician not to be notified that Resident #1 had decreased oral intake for several days. The DON said she knew the Corporate Nurse had conducted multiple in-services during her time as the Interim DON. The DON said she started at the facility on 3/26/24 and had conducted in-services over notification on 3/29/24. The DON said the facility had no intake/output records to provide for Resident #1. She explained unless a resident had a specific order for intake and output monitoring the records were generally not entered. The DON said she did look to see if there were any paper intake records to provide but there were none. During an interview on 4/12/24 at 10:22 a.m., LVN A said she did remember being notified Resident #1 was refusing medications but could not recall the exact date. LVN A said she had notified the DON at the time (DON X) but had not notified the Physician or Nurse Practitioner. LVN A said the former DON (DON X) had told her that Resident #1 was going to go on hospice. LVN A said the assumed the DON had would take care of the notification if it was needed. LVN A said she never saw any paperwork and Resident #1 was never put on hospice. LVN A said Resident #1 had an overall decline in the few weeks before his hospitalization after his family member had discharged home. LVN A said he had a decrease in oral intake and increased combative behaviors. LVN A said again she had not notified the physician but had notified the DON under the assumption the DON was attempting to move him to hospice care. LVN A said she could not recall Resident #1 having an order for CBC, CMP and UA/CS on 1/13/24. LVN A said she should have documented the refusal of care (including the refusal of medications and ordered labs) should have been documented in the progress notes; the Physician or the Nurse Practitioner notified and the notification documented in the progress notes. During an interview on 4/12/24 at 1:47 p.m., the Nurse Practitioner said she had not been notified prior to 1/22/24 that Resident #1 had decreased oral intake in the days leading up to 1/22/24. The Nurse Practitioner said she had not been notified Resident #1 had been refusing medications and was not notified Resident #1 refused ordered labs. The Nurse Practitioner said the labs had been ordered on 1/13/24 by Resident #1's physician because a CNA had reported Resident #1 had increased agitation. The Nurse Practitioner said there was no documentation that Resident #1's physician had been notified of Resident #1's decreased oral intake for days leading up to his hospitalization , medication refusals leading up to hospitalization or refusal of the ordered labs. The Nurse Practitioner said had she been notified of she would have ordered to have Resident #1 sent to hospital sooner. During an interview on 4/12/24 at 3:20 p.m., ADON P said the Physician and/or Nurse Practitioner should have been notified that the labs ordered on 1/13/24 had been refused by Resident #1. ADON P said it was not acceptable to fail to notify the medical provider that a resident had been refusing oral medications for four days. ADON P said the medical provider should have been notified with each refusal. ADON P said it was not acceptable for the physician not to be notified that Resident #1 had decreased oral intake for several days. ADON P said DON Q had completed an in-service over notification but would ensure more specific in-services would be completed as well. During an interview on 4/12/24 at 3:40 p.m., the Administrator said she started at the facility in February of 2024. The Administrator said she expected staff to follow policy and procedure related to physician notification. The Administrator said she believed the DON had conducted in-services over notification. During an interview on 4/13/24 at 12:41 p.m., Resident #1's Physician said he had no recollection or documentation that the facility had notified him regarding Resident #1's decreased oral intake for days leading up to his hospitalization , medication refusals leading up to hospitalization or refusal of the ordered labs. Record review of the facility policy and procedure dated 03/01/23 titled Notification of Changes stated, Policy: the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician .when there is a change requiring notification Circumstances requiring notification include: (2) Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include (a) Life threatening conditions or (b) Clinical complications. (3) Circumstances that require a need to alter treatment . Record review of the facility policy and procedure dated March of 2022, titled Medication Administration stated, Policy: Medications are administered .as ordered by the physician in accordance with professional standards of practice .(19) Report and document any adverse effects or refusals . The Administrator was notified on 4/12/24 at 5:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template on 4/12/24 at 5:43 p.m. The facility's Plan of Removal was accepted on 4/13/24 at 1:22 p.m. and included: *The Medical Director was notified by the Assistant Director of Nursing on 4/12/24. The medical director was notified of the concurrent IJ on 4/13/24 by the VP of Clinical Operation. *Nursing staff were in-serviced on 4/12/24 regarding change in condition and refusal of care notification of the provider, DON, and RP, by the ADON and VP of Clinical Operations. All nurses will be in-serviced on this procedure prior to the start of their shift. *The DON and ADON will monitor documentation, as part of the daily clinical meeting, to ensure that any residents who refuse care, all notifications were completed. The DON and ADON were in-serviced by the VP of Clinical Operations on 4/13/24. On 4/13/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an interview on 4/13/24 at 12:41 p.m., the Medical Director confirmed he had been notified of the Immediate Jeopardy regarding notification on 4/13/24. Record review of the facility's audit document dated 4/13/24 reflected the ADON reviewed all residents for the last 24 hours, to determine if any residents who refused care, had the proper notifications documented. During an interview on 4/13/24 at 12:57 p.m., ADON P confirmed she reviewed all residents for the last 24 hours, to determine if any residents who refused care, had the proper notifications documented. She said the review included MAR/TAR review and nursing progress notes. ADON P said no refusals without documentation/notification were identified. ADON P said herself and the DON will would continue to monitor documentation, as part of the daily clinical meeting, to ensure that any residents who refused care had all notifications completed (medical provider, family and RP as pertinent). During an interview on 4/13/24 at 3:21 p.m., DON Q said she would continue to monitor documentation, as part of the daily clinical meeting, to ensure that any residents who refused care had all notifications completed (medical provider, family and RP as pertinent). Record review of the in-service training report and accompanied sign in sheet dated 4/12/24, titled Residents that refuse care, indicated nursing in-services over response to resident refusal of care was to include provider notification and documentation of that notification, as well as family and/or RP notification, had been initiated. Record review of the in-service training report and accompanied sign in sheet dated 4/12/24, titled Resident Change of Condition, indicated direct care staff in-services over any change in resident condition was to be communicated to the charge nurse and the charge nurse was to assess the resident, document the change on the 24 hour report and notifications (provider, RP and family)completed. Staff interviewed on 4/13/24 between 1:30 p.m. and 3:38 p.m., (LVN O, LVN I, LVN N, LVN BB, LVN A, LVN R, LVN C, MA M, CNA S, CNA T, CNA L, CNA V, CNA W, HA U, MA H and CNA AA [this was all direct care staff from all shifts that had worked since 4/12/24]) MAs indicated that if a resident refused a medication they would notify the nurse promptly and that each med pass refusal would require notification to the charge nurse. CNAs said if the noticed an abrupt or gradual change in a resident's intake they would notify the nurse. The nurses said they would document any medication refusal and notify the medical provider as well as the resident RP. Nurses said if they were notified a resident had decrease (abrupt or gradual) in oral intake they would notify the physician, DON and responsible party. Nurses said if a resident refused ordered labs they would notify the medical provider, the DON and the RP. Nurses indicated that part of the daily clinical stand-up meeting was discussing any changes in resident condition, behaviors and status. During an interview on 4/13/24 at 3:40 p.m., the Administrator said no staff would be allowed to work until they completed in-services. While the IJ was removed on 4/13/24 at 3:44 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record review the facility failed to ensure a resident who had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain for 1 of 6 (Resident #1) residents reviewed for urinary catheters. The facility did not ensure the needed an order for catheter care was entered when Resident #1 returned from the hospital with a Foley catheter in place on 1/1/24. The facility did not ensure catheter care was documented for Resident #1 from 1/1/24 to 1/17/24. The facility did not ensure Resident #1 was provided catheter care from 1/1/24 to 1/17/24. The facility did not clearly document the discontinuation of Resident #1's foley catheter or circumstances for it's discontinuation. Resident #1 was admitted to the hospital on 1/22/24 and was found to have Urosepsis (sepsis caused by infections of the urinary tract). Resident #1 passed away at the hospital on 1/22/24. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 4/12/24 at 5:12 p.m. While the IJ was removed on 4/13/24, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place residents at risk of urinary tract infections, sepsis (sepsis occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body) and death. Findings included: Record review of the face sheet dated 3/28/24 indicated Resident #1 was an 87- year- old male admitted to the facility on [DATE] with diagnoses including, aftercare following joint replacement surgery, fracture of the right femur (the head of the hip joint), acute bronchitis, bradycardia (slow heart rate), dementia, sick sinus syndrome (disease in which the heart's natural pacemaker becomes damaged and is no longer able to generate normal heartbeats at the normal rate), presence of a cardiac pacemaker, insulin dependent diabetes with chronic kidney disease, and high blood pressure. Record review of the baseline care plan 12/22/24 for Resident #1 indicated he had the potential /actual elimination deficit related to bowel incontinence and bladder incontinence. The care plan interventions included use/ incontinent pads /briefs/pull- ups as needed. The baseline care plan did not indicate Resident #1 had a catheter. Record review of the comprehensive care plan dated 1/5/24 for Resident #1 did not indicate Resident #1 had a catheter. Record review of the nursing note dated 12/31/24 at 6:17 p.m., stated Notified by aide resident did not have output this shift, VS (vital signs):109/74 (blood pressure),67 (pulse),18 (respiration rate) ,98.9 (temperature) 92% (oxygen saturation) at room air. Resident lethargic. NP (Nurse Practitioner) notified. Order for straight cath (catheter) if no output send to ER. No output noted, TX nurse at bedside to assist. EMS notified Residents RP . DON made aware. This note was written by LVN A. Record review of the hospital discharge instructions/ summary dated 12/31/23 indicated Resident #1 had a diagnosis of urinary retention and was returning to the facility with a Foley catheter in place. Record review of the physician's order summary report from 12/21/23 to 1/22/24 found it did not list an order for catheter care. Record review of the nursing note dated 1/1/24 at 9:01 a.m., stated Resident returned from hospital via EMS at approx. (approximately) 0900 (9:00 a.m.) to room . foley catheter in place r/t (related to) urinary retention. Call light placed within reach. DON and NP aware. This note was written by LVN I. Record review of the daily skilled nursing notes from 1/1/24 to 1/17/24 indicated Resident #1 had a Foley catheter in place on the following dates; *01/02/2024- (this skilled note was completed by LVN I); *01/05/2024- (this skilled note was completed by LVN I); *01/07/2024- (this skilled note was completed by LVN E); *01/10/2024- (this skilled note was completed by LVN E); *01/11/2024- (this skilled note was completed by LVN E); *01/14/2024- (this skilled note was completed by LVN Z); *01/16/2024- (this skilled note was completed by LVN I); and *01/17/2024- this skilled note was completed by LVN I). None of the daily skilled notes indicated catheter care was provided to Resident #1. Record review of the daily skilled nursing note on 1/18/24 indicated Resident #1 did not have a Foley catheter in place. Record review of nursing progress notes from 1/2/24- 1/22/24 found documentation of Resident #1's foley catheter being in place on 1/2/23 and 1/3/24. These notes did not indicate catheter care was provided. There was no other documentation regarding Resident #1's Foley catheter from 1/3/24 to 1/22/24 in the nursing progress notes. Record review of the MAR for January 2024 did not indicate Resident #1 had received catheter care. There was no order on the MAR for Foley catheter care. Record review of the facility staffing assignment sheets from 1/1/24 to 1/18/24 indicated LVN E had been assigned to Resident #1 two of the days from 6:00 a.m. to 6:00 p.m. During an interview on 4/10/24 at 12:55 p.m., LVN E said she remembered Resident #1 but could not remember if he had a catheter. LVN E said if she had provided catheter care to Resident #1 it should be documented on Resident #1's MAR. LVN E said it was important to provide catheter to decrease the risk of infection. Record review of the facility staffing assignment sheets from 1/1/24 to 1/18/24 indicated LVN I had been assigned to Resident #1 nine of the days from 6:00 a.m. to 6:00 p.m. During an interview on 4/10/24 at 3:00 p.m., LVN I said she could not recall if Resident #1 had a catheter. LVN I said she could not recall performing catheter care for Resident #1 because she could not recall if he had a catheter. LVN I said if Resident #1 had a catheter then she would have documented catheter care on the MAR. LVN I said when a resident returned from the hospital with a catheter in place there was a set orders entered related to the catheter and those orders included catheter care on each shift. LVN I said the nurse receiving the resident usually puts the orders in but that the DON or ADON would also assist with entering the necessary orders. LVN I said she did not recall being the nurse that received Resident #1 from the hospital on 1/1/24 and could not recall if she entered orders or if DON X or ADON Y had entered the orders. LVN I said it was important for the order to be entered as it would prompt the nurse to complete catheter care. LVN I said it was important for nurses to complete catheter care to help prevent bladder infections. Record review of the facility staffing assignment sheets from 1/1/24 to 1/18/24 indicated LVN A had been assigned to Resident #1 six of the days from 6:00 a.m. to 6:00 p.m. During an interview on 4/12/24 at 10:22 a.m., LVN A said she remembered Resident #1 and remembered he had a catheter. LVN A said she remembered performing catheter care and it should be documented on Resident #1's MAR. LVN A said she did not think Resident #1 had a catheter the entire time he was at the facility. LVN A said she had heard he had pulled it out but could not say for sure. LVN A said it was important for the resident to with catheters to receive catheter care to decrease the risk of infection. Record review of the nursing progress note dated 1/22/24 at 8:58 a.m. stated, spoke with .NP (nurse practitioner) and DON about the resident change of condition. Resident has not eaten or had any fluids x3 days although they have been highly encouraged. Upon assessing resident after getting report from (previous shift nurse) that resident went from being alert and combative to very lethargic and slow to respond to pain stimuli .Vitals were wnl (within normal limits) but blood sugar was 445 .orders were to send him out for further evaluation . Record review of the hospital problems list dated 1/22/24 stated Resident #1 had a primary diagnosis of sepsis with encephalopathy (a broad term for any brain disease that alters brain function or structure, causes include infection) without shock (condition that occurs when the body is not getting enough blood flow). Record review of the hospital critical care note dated 1/22/24 indicated Resident #1 had been diagnosed with urosepsis (sepsis caused by infections of the urinary tract). The note detailed that the presumed source of sepsis was a urinary tract infection with MRSA (staph infection that is difficult to treat because of resistance to some antibiotics). Record review of the hospital final disposition of body report dated 1/28/24 indicated Resident #1 had passed away. The cause of death was identified as sepsis. During an interview with ADON P on 4/12/24 at 3:20 p.m., ADON P said she had been at the facility as the ADON since 02/19/24. ADON P said the VP of clinical operations was the interim DON at that time and they were working to correct a lot of issues at the facility. ADON P said nurses should be performing catheter care each shift and as needed. ADON P said catheter care was important to decrease the risk of urinary tract infections. ADON P said the system in place to ensure residents received catheter care was to ensure the appropriate orders were entered for catheter care. ADON P said since she had been with the facility morning clinical meetings were held Monday through Friday. ADON P said during these clinical meetings every resident in the facility was reviewed. ADON P said part of this clinical meeting was reviewing any new admissions, re-admissions and any residents that had been out to the hospital, had all appropriate orders entered for any new appliances they might have received while out of the facility such as catheters. ADON P said she believed she had performed an audit at the beginning of April 2024 to ensure residents with catheters had appropriate orders and nurses were documenting catheter care. During an interview with DON Q on 4/12/24 at 3:35 p.m., DON Q said she had been at the facility as the DON since 3/26/24. DON Q said the VP of clinical operations had been acting as the interim DON. DON Q said the previous DON (DON X) had been terminated and walked out of the facility. DON Q said they were working to correct a lot of issues at the facility. DON Q said nurses should be performing catheter care each shift and as needed. DON Q said it was important to ensure residents with catheters received catheter care to decrease the risk of urinary tract infections. DON Q said since she had been with the facility morning clinical meetings had been daily Monday through Friday. DON Q said part of this clinical meeting was reviewing any new admissions, re-admissions and any residents that had been out to the hospital had all appropriate orders entered for any new appliances they had such as catheters. Record review of the facility policy and procedure dated July of 2022, titled Catheter Care, stated It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . Policy Explanation (1) Catheter care will be performed every shift and as needed by nursing personnel . An interview was attempted with ADON Y (the former ADON) regarding catheter care and order entry process on the following dates 4/10/24 and 4/11/24 but was not completed. An interview was attempted with DON X (the former DON) on the following dates 4/9/24 and 4/10/24 but was not completed. The Administrator was notified on 4/12/24 at 5:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template on 4/12/24 at 5:43 p.m. The facility's Plan of Removal was accepted on 4/13/24 at 9:36 a.m. and included: *The Medical Director was notified by the Assistant Director of Nursing on 4/12/24. *All residents with indwelling catheters were audited by the ADON on 4/2/24 and again 4/12/24, to ensure all catheter care orders were in place. *Daily clinical meeting has been held daily M-F since February 16, 2024. In this clinical meeting, the new order listing, 24-hour report, and omissions report were reviewed. All new admits, and re-admits were also reviewed by the DON, the ADON, the MDS, the Treatment Nurse, and the Administrator. Any residents sent to the ER were also reviewed/hospital records were reviewed for changes or new orders. This process has been in place since February 2024. *Action plan was in place to ensure the facility staff were aware of the expectation of what was to be reviewed in the daily clinical meeting by the VPCO and documented. This daily clinical meeting has been held since February 16, 2024, by the VP of Clinical Operations (interim DON at that time), and now held by the current DON since March 26, 2024. The action plan was implemented 3/26/24, for all of the company's facilities as a reminder of the process, by the VP of Clinical Operations. *All nurses on shift at this time were in-serviced on initiating catheter care orders for any new catheter orders, admission, or readmission catheter orders, by the ADON on 4/12/24. All remaining nurses will be in-serviced on this policy prior to their shift. *All nursing staff present on 4/12/24, received written procedure related to catheter care by the ADON on 4/12/24. All nursing staff will be provided with the written procedure on catheter care prior to their shift, by ADON or VP of Clinical Operations, beginning 04/13/24. *All nurses present at this time, 4/13/24, have received in-service education on implementing the catheter care orders for any resident with a new catheter. All nurses will be in-serviced on this process prior to their shift, by the ADON or VP of Clinical Services. *Medical Director - The Medical Director has been notified of the Immediate Jeopardy. *QAPI Committee Review - An interim QAPI committee meeting was completed on 04/12/2024. On 4/13/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the other six sampled residents on 4/12/24 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) found that orders for catheter care were in place and catheter care was being documented. During an observation on 4/12/24 at 12:45 p.m., catheter care was observed for Resident #6. No failures were identified during the catheter care. During an observation on 4/12/24 at 1:30 p.m., catheter care was observed for Resident #2. No failures were identified during the catheter care. During an interview on 4/13/24 at 12:41 p.m., the Medical Director confirmed he had been notified of the Immediate Jeopardy on 4/12/24 and attended the interim QAPI meeting via phone. Record review of the facility audit documents dated 4/2/24 detailed the facility residents with indwelling catheters (9 residents) had the necessary order batch in place (including the order for catheter care), and care was being documented. Record review of the facility audit documents dated 4/12/24 detailed the facility residents with indwelling catheters (11) had the necessary order batch in place (including the order for catheter care), and care was being documented. Record review of the daily clinical meeting sign sheets from 2/16/24 to 4/12/24 were reviewed and indicated daily clinical stand- up meeting was held daily Monday through Friday 2/16/24 to 4/12/24. Record review of the facility Action Plan dated 3/26/24 titled AM clinical meeting stated the clinical meeting would be held Monday through Friday after the morning standup meeting. The action plan included that all new residents were to be reviewed in the clinical meeting and all associated orders entered. Record review of the facility QA agenda and sign in sheet dated 4/12/24 reflected a QA meeting with the Medical Director in attendance via phone was held on 4/12/24 regarding the facilities Plan of Removal related to Immediate Jeopardy. During an interview on 4/12/24 at 5:50 p.m., the VP of clinical operations said the Action plan was put in place to ensure all facility staff were made of aware of what was expected in regards to daily clinical meeting, including the review of all new admissions, re-admissions, and any residents that had been sent to the ER and returned to the facility without discharge. The VP of clinical operations said this review would include ensuring all new orders were entered and any new medical appliances, such peripheral IV's , PICC lines, feeding tubes, and indwelling catheters etc., had the appropriate orders for care. The VP of Clinical operations said she had been the interim DON and held the meetings since from 2/16/24 until 3/26/24 at which time the new DON (DON Q) held the meetings. During an interview on 4/13/24 at 12:57 p.m., ADON P said the daily clinical meetings that she knew had been in place since she started at the facility would continue to ensure new admissions, re-admissions, and any residents that had been out to the hospital and returned to the facility had all appropriate orders entered for any new appliances they had such as catheters. ADON P said she had performed and additional audits of all residents in the facility with catheters on 4/12/24 and all residents had the appropriate orders and care implemented. ADON P said no staff would return to work until they had received the in-service over Catheter Care orders for new catheters. During an interview on 4/13/24 at 3:21 p.m., DON Q said the daily clinical meetings that she knew had been in place since she started at the facility would continue to ensure new admissions, re-admissions, and any residents that had been out to the hospital and returned to the facility had all appropriate orders entered for any new appliances they had such as catheters. DON Q said no staff would return to work until they had received the in-service over Catheter Care orders. Record review of the in-service training report and accompanied sign in sheet dated 4/12/24, Titled Catheter Care orders for new catheters, indicated nursing in-services over ensuring catheter care orders were initiated for all admissions, re-admissions, or new catheter as appropriate. Nurses interviewed on 4/13/24 between 1:30 p.m. and 3:38 p.m., (LVN O, LVN I, LVN N, LVN BB, LVN A, LVN R, and LVN C) confirmed all nurses that worked on 4/12/24 and 4/13/24 (both on the 6a.m.-6:00 p.m.) had received in-services over ensuring catheter care orders were initiated. The nurses said residents with catheters were to receive catheter care every shift and as needed. The nurses said they would document catheter care provided on the resident's MAR. The nurses explained that when the order batch for catheters were entered it included an order for catheter care, which once entered will display on the MAR. The nurses said they had been instructed on how to enter these orders if a resident with a catheter was found to not have the batch orders for catheters entered. The nurses said if they had any trouble entering the orders, they would document the catheter care on they provided on a nursing progress note and notify the DON or the ADON that they needed assistance entering the batch orders. The nurses said they attended the morning meetings and provided a report on each resident they cared for. The day shift nurses said the daily stand- up meetings included any new admissions, re-admissions, or residents that had been out of the facility to the hospital. The nurses said any new devices or appliances the resident might have, were discussed, and reviewed to ensure any associated orders and care were implemented. They said this included catheters. The nurses also indicated they had received the catheter care procedure list and verbalized appropriate steps for catheter care. During an interview on 4/13/24 at 3:39 p.m., the Administrator said all nurses that have worked since the identification of the IJ had received in-services and that no nurse would be allowed to work until in-services were completed. While the IJ was removed on 4/13/24 at 3:44 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interviews, and record review, the facility failed to provide care that would ensure acceptable parameters of nutritional status for 1 of 6 residents reviewed for nutritional status. (Resident #1). The facility did not appropriately monitor Resident #1's weights during his stay at the facility from 12/21/23 to 1/22/24 and it resulted in Resident #1 had a 15 % weight loss in 26 days. This noncompliance was identified as PNC. The non-compliance began on 12/21/23 and ended 2/29/24. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for altered nutritional status, and complications of chronic conditions, and decline in health status. Findings included: Record review of the face sheet dated 3/28/24 indicated Resident #1 was an 87- year-s old male admitted to the facility on [DATE] with diagnoses including, aftercare following joint replacement surgery, fracture of the right femur (the head of the hip joint), acute bronchitis, bradycardia (slow heart rate), dementia, sick sinus syndrome (disease in which the heart's natural pacemaker becomes damaged and is no longer able to generate normal heartbeats at the normal rate) presence of a cardiac pacemaker, insulin dependent diabetes with chronic kidney disease, and high blood pressure. Record review of Resident #1's MDS dated [DATE] indicated he usually understood others and usually made himself understood. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 6). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #1 was dependent on staff for lower body dressing and the putting on/taking off of footwear. The MDS indicated Resident #1 required moderate assistance with upper body dressing, showering, and toileting. The MDS indicated he required supervision or touch assistance with personal hygiene and eating. The MDS indicated he required set up or clean up assistance only with eating. The MDS indicated Resident #1 dependent on staff for sit to stand transfers, chair/bed- to- chair transfers, toilet transfers, and tub/shower transfers. The MDS indicated Resident #1 required substantial/maximal assistance with walking ten feet, and the ability to move from lying on the back to sitting on the side of the bed with no back support. The MDS indicated Resident #1 supervision or touch assistance with the ability to roll to the left or right side while in the bed and the ability to move from setting on the side of the bed to lying flat on the bed. The MDS indicated Resident #1 was occasionally incontinent of bladder and was always incontinent of bowel. The MDS indicated Resident #1 was 75 inches tall (6 feet 3 inches) and weighed 159 lbs. The MDS indicated Resident #1 had no significant weight gain or loss in the last 6 months. The MDS indicated during the 7 days look back period while not a resident at the facility, Resident #1 had received Parenteral/IV (feeding through a vein). The MDS indicated during the 7 days look back period while a resident at the facility, Resident #1 had received a mechanically altered, therapeutic diet. The MDS indicated he had an active diagnosis of protein or calorie malnutrition or was at risk for malnutrition. Record review of the care plan dated 12/22/23 for Resident #1 indicated he was at risk for dehydration and malnutrition. The care plan interventions included mechanical soft diet and vitamin supplements. The care plan also indicated Resident #1 would receive ST and was dependent on staff for all care. Record review of the physician order summary report from 12/21/23 to 1/22/24 reflected Resident #1 had the following physician orders.; *daily weight .start date 12/22/24; *Prostat 30 ml twice a day for 60 days, start date 1/12/24; *multi-vitamin 1 tablet once a day for 60 days, start date 1/12/24; *vitamin C 500 mg 1 tablet twice a day for 60 days, start date 1/12/24; *zinc sulfate 220 mg 1 tablet once a day for 6 days, start date 1/12/24; During an interview on 3/28/24 at 11:00 a.m., LVN Z said Resident #1 had been started on the Prostat, multi-vitamin vitamin C, and zinc as part of a wound protocol order set on 1/12/24, not because he had been identified as nutritional risk or significant weight loss. Record review of the Hospital discharge summary dated 12/21/23 indicated Resident #1's weight was 157 lb. and 13.6 oz. Record review of nursing progress notes from 12/21/23 to 1/22/24 displayed no weights for Resident #1. Record review of the nutrition risk assessment for Resident #1 dated 12/27/23 stated his most recent weight was 159.4 lbs. (a date was not specified). The nutrition risk assessment stated Resident #1 was at high nutritional risk at that time and was underweight with a BMI of 19 and had increased nutrient needs. The note indicated the Resident ate fair consuming approximately 25-50 percent of most meals with minimal assist/supervision/cueing. The nutritional interventions recommended by the RD at that time were fortified foods, offer snacks three times a day, Medpass 90 ml three times a day, Liquid protein 30 ml twice a day, a daily multivitamin, and vitamin C 500 mg BID. This note was written by the RD. Record review of the nursing progress notes from 12/21/23 to 1/1/24 revealed there was no documentation regarding Resident #1's oral intake. Record review of the nursing progress note dated 1/2/24 at 2:51 a.m., indicated Resident #1 took oral fluids fair. This note was written by LVN BB. Record review of the nursing progress note dated 1/3/24 at 12:23 a.m., indicated Resident #1 took oral fluids fair. This note was written by LVN BB. Record review of the nursing progress notes from 1/4/24 to 1/21/24 revealed there was no documentation regarding Resident #1's oral intake. Record review of the nursing progress note dated 1/22/24 at 4:09 a.m., Indicated Resident #1 had not eaten breakfast lunch or dinner on 1/21/24, was combative during care and fluids were taken poorly. This note was written by LVN BB. Record review of the nursing progress note dated 1/22/24 at 8:58 am stated spoke with .NP (nurse practitioner) and the DON about the resident change of condition. Resident has not eaten or had any fluids x3 days although they have been highly encouraged. Upon assessing resident after getting report from (previous shift nurse) that resident went from being alert and combative to very lethargic and slow to respond to pain stimuli .Vitals were wnl (within normal limits) but blood sugar was 445 .orders were to send him out for further evaluation . This note was written by LVN D. Record review of the Hospital Critical Care History and Physical described Resident #1 as cachectic (general state of ill health involving great weight loss and muscle loss) in appearance and listed unintentional weight loss as an active problem, indicating the need to rule out malignancy and that NGT tube would be placed if indicated. The History and Physical listed the principal diagnosis of Sepsis with encephalopathy. Record review of the hospital pharmacy consult note dated 1/23/24 indicated Resident #1's weight was 135 lb. and 12.9 oz. During an interview on 3/11/24 at 10:00 am, the VPCO said she was acting as the DON. She said the DON and ADON had been terminated for multiple issues identified by the facility including issues with the oversight of weight assessments. The corporate RN said there was a performance improvement plan in place that the QAPI committee was overseeing. During an interview on 3/12/24 at 10:10 a.m., LVN A said new admissions were to be weighed weekly for 4 weeks. LVN A said as a nurse this was something she checks on now. LVN A said residents were weighed monthly after 4 weeks of weekly weights, unless there was an order to weigh more often. LVN A said the weekly weights were completed by the restorative aide. During an interview on 3/12/24 at 10:23 a.m., LVN E said all new admissions were weighed weekly for 4 weeks, then monthly unless ordered more frequently, or if the resident has had an order to stop weights. During an interview on 3/12/24 at 10:47 a.m., LVN F said all new admissions were weighed weekly for 4 weeks, then monthly unless ordered more frequently, or if the resident has had an order to stop weights. During an interview on 3/12/24 at 12:54 pm, Resident #1's family member said she shared a room at the facility with Resident #1 until a few weeks before he had to go the hospital (1/13/24). She said she could recall the staff coming to get him to weigh him regularly. Resident #1's significant other said she thought maybe one time they came to get him and said they were going to weigh him. She said she was weighed every day. Resident #1 said he was going to the dining room regularly to eat lunch with a friend, but would usually be in the room for breakfast and dinner. Resident #1's significant other said Resident #1 could eat better on his own but that he seemed to eat more when staff assisted him. During an interview with the DON on 3/28/24 at 10:00 am, she stated weights were currently being reviewed during the daily meeting. The DON said she was new to the facility but that the monitoring of weights and interventions as needed was something she continued to keep a close eye on. The DON clarified,; weight lists were reviewed during the daily stand-up meeting. Weights were being obtained by the same staff member, CNA B, for accuracy and the CNA gave the weights to her. The DON said Resident #1 should have been weighed weekly on his admission. During an interview on 3/28/24 at 10:20 a.m., CNA B said she was new to her role as staffing coordinator/restorative and has been obtaining resident weights. CNA B said all new admissions/re-admissions were to be weighed weekly for 4 weeks. CNA B said she also performs daily weights for residents as directed by the DON. CNA B said most residents get weighed monthly. During an interview on 3/28/24 at 10:53 a.m., the RD said she comes the facility weekly. The RD said she printed a report that notified her of all significant weight changes, new admissions, and residents with wounds. The RD said that was how she knew which residents to prioritize week to week. She said if weight information was not documented in EMR system the report she prints would not identify any weight changes. The RD said she did see Resident #1 upon his most recent admission on 12/27/23. When asked how the RD had the information of Resident #1's weight on 12/27/23, she stated if the weight was not documented in the EMR, she would have told staff she needed a weight for him, and they would have obtained it for her. The RD said Resident #1 would have shown on the report as a new admission, and it appeared that was why she saw him according to her note on 12/27/23. The RD said she had no other notes for Resident #1, but had he flagged as significant weight loss she would have seen him again. During an interview on 3/28/24 at 12:20 p.m., the Administrator said the facility policy and procedure should have been followed. She said Resident #1 should have had daily weights as ordered. Items such as this were part of the DON's termination and implementation of facility action to ensure corrective measures were taken. Record review of the facility assignment sheets from 1/18/24 to 1/22/24 indicated LVN A took care of Resident #1 on 1/18/24 from 6am-6pm and MA H passed medications to Resident #1 on 1/18/24. The facility assignment sheets indicated MA G was assigned to Resident #1 on 1/19/24 -1/21/24. The assignment sheets indicated LVN I took care of Resident #1 on 1/19/24 from 6am -6pm. The assignment sheets indicated LVN D had taken care of Resident #1 from 6am-6pm on 1/20/24-1/22/24. The facility assignment sheets indicated CNA K took care of Resident #1 from 6a-6p on 1/19/24 and 1/21/24. The facility assignment sheets indicated CNA J took care of Resident #1 on 1/20/24. During an interview on 4/9/24 at 3:50 p.m., CNA K said she could not recall Resident #1. CNA K said she could not remember if Resident #1 had decreased intake. CNA K said if any Resident had a decrease in their food or fluid intake, she would notify the nurse caring for that Resident. During an interview on 4/9/24 at 3:54 p.m., CNA J said she remembered Resident #1 and took care of him regularly during his most recent stay at the facility (12/21/23 to 1/22/24). CNA J said Resident #1 had good days and bad days in regard to his oral intake. CNA J said towards the end of his stay it did seem Resident #1 had declined. CNA J said she could not say that his oral intake had decreased substantially but would have notified the nurse caring for Resident #1 if she had noticed a decrease in his intake. During an interview on 4/10/24 at 3:00 p.m., LVN I said she could not recall if any CNA had reported to her that Resident #1 had decreased intake. During an interview on 4/10/24 at 3:29 p.m., LVN D said that it had been reported to him before his shift on 1/22/24 that Resident #1 had decreased intake over the past 3 days and had no input in the past 24 hours. LVN D was asked to clarify his statement as his note written on 1/22/24 stated Resident has not eaten or had any fluids x3 days. LVN D said that was a mistake, he said Resident #1 had no intake x3 meals (in the past 24 hours) and a decrease in intake in the days leading up to 1/22/24, based on what had been reported to him. LVN D said he could not recall the night shift nurse he received report from. During an interview on 4/11/24 at 2:00 p.m., DON Q said the facility had no intake/output records to provide for Resident #1. She explained unless a resident had a specific order for intake and output monitoring the records are generally not entered. The DON said she did look to see if there were any paper intake records to provide but there were none. During an interview on 4/12/24 at 10:22 a.m., LVN A said Resident #1 had overall decline in the few weeks before his hospitalization after his wife had discharged home. LVN A said he had a decrease in oral intake and increased combative behaviors. LVN A said she had not notified the physician but had notified DON X under the assumption DON X was attempting to move him to hospice care. During an interview on 4/12/24 at 1:47 p.m., the Nurse Practitioner said she had not been notified prior to 1/22/24 that Resident #1 had decreased oral intake in the days leading up to 1/22/24. The Nurse Practitioner said she had not been notified of Resident #1's dietary recommendations on 12/27/23. The Nurse Practitioner said had she been notified she would have ordered all of the Dietitians recommendations. During an interview on 4/13/24 at 3:30 p.m., LVN BB said she could not remember Resident #1. Record review of the facility policy and procedure dated June of 2022, titled Weight Monitoring, stated Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status such as usual body weight or desirable body weight range .(5) A weight monitoring schedule will be developed upon admission for all residents: .(b) newly admitted weights -monitor weight weekly for 4 weeks. (c) Residents with weight loss- monitor weight weekly. (d) if clinically indicated -monitor weight daily. ( e) All others - monitor weight monthly. The facility had corrected the noncompliance by the following: - Termination of the DON and ADON that were to be overseeing weight assessments. - Notification of the Medical Director /NP - All residents being weighed - All new admits/ re-admits being weighed weekly x 4 weeks - Review of weights in the weekly in the weight/skin meeting - Back up plan established for the DON or acting DON to assign staff to obtain weights in the absence of the restorative aide - The DON/designee will enter weights into EMR system Record review of a Quality Assurance (QA) Meeting Sign-in Sheet dated 2/14/24 indicated the facility had an QA meeting addressing weight assessments. The QA Meeting Sign-in Sheet indicated the nurse practitioner was present for the QA meeting. Record review of the Action Plan regarding weights dated 2/21/24 revealed: - All residents being weighed - All new admits/ re-admits being weighed weekly x 4 weeks - Review of weights in the weekly in the weight/skin meeting - Back up plan established for the DON or acting DON to assign staff to obtain weights in the absence of the restorative aide - DON/designee will enter weights into PCC Record review of the Weekly weights log dated 3/27/24 displayed all new admissions/readmissions weights obtained weekly. Record review of the Resident Weight summary report dated 3/28/24, displayed historical data for 90 days. Record review of the sampled residents ((Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) revealed weights obtained appropriately and documented in the EMR. All staff interviewed (LVN A, CNA B, LVN E, LVN F, LVN C) on 3/28/24 verbalized that all new admission and re/admissions were to be weighed weekly x 4 weeks. All residents were to be weighed monthly unless given a specific order to weigh more often or less often (in the case of being ordered by hospice provider). The noncompliance was identified as PNC. The noncompliance began on 12/21/22 and ended on 2/29/23. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for 1 of 17 residents (Resident #1) reviewed for accidents and supervision, falls and resident neglect. CNA A did not ensure Resident #1 was safe when assisting with incontinent care. Resident #1 rolled out of bed during care and sustained a fracture right hip. An Immediate Jeopardy (IJ) situation was identified on 06/05/23 at 5:20 p.m. While the IJ was removed on 06/07/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: Review of a face-sheet dated 06/02/23 showed Resident #1 was an [AGE] year-old female first admitted to the facility on [DATE] with diagnoses of Dementia, cognitive communication deficit, muscle weakness, lack of coordination, hypertension, Pseudobulbar affect, (condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying) and readmitted on [DATE] with diagnoses of closed fracture (break) with routine healing and Pneumonia. Review of MDS dated [DATE] showed Resident #1 was alert and oriented with a BIMS score of 15 which indicated she was cognitively intact and aware of person, place, and time. She required two-person assistance with bed mobility and toileting. Review of MDS dated [DATE] showed Resident #1 was alert and oriented with a BIMS score of 15 which indicated she was cognitively intact and aware of person, place, and time. She required two-person assistance with bed mobility and toileting. Record review of nurse progress notes dated 02/07/23 at 11:19 a.m. showed Notified by aide resident slide out of bed during incontinent care, went to assess resident. Resident noted sitting on left side of bed on buttocks, VS: 136/78, 68, 20, 97.8. asked resident if in pain lifted left hand stated it's sore. Asked resident what happened, just shrugs shoulders. Denies hitting head, purple bruise noted to residents left hand. Assisted resident back in bed. Tylenol 325 (Pain medication) x 2 tabs given per orders; MD made aware DON made aware. Resident RP notified, Review of nurse progress notes for Resident #1 dated 02/07/23 at 3:03 p.m. showed Resident complained of pain to bilateral legs and left hand. NP notified. New orders for x-ray legs and left hand Review of nurse progress notes for Resident #1 dated 02/08/23 at 2:31 a.m. showed Resident resting in bed. Bruising noted to left hand from fall. No complaints voiced at this time. X-ray has not shown up so far this shift. Review of nurse progress notes for Resident #1 dated 02/08/23 and 02/09/23 showed 2 COVID19 test were given and both tests were negative. Review of Nurse Progress notes for Resident #1 dated 02/09/23 at 2:11 p.m. showed Resident was sent to the ER per NP request for having diminished chest sounds . Resident had temperature of 99.6, BP 103/61. RESP: 17, Pulse 97, Oxygen 65-67%. DON and family aware. Review of x-ray report for Resident #1 dated 02/08/23 showed there is a nondisplaced intertrochanteric fracture of the right femur (large leg bone) of indeterminate age. There is no dislocation. Review of hospital records for Resident #1 dated 02/09/23 at 5:06 p.m. showed Resident #1 was admitted due to low Oxygen saturation of 69%. Resident #1 was placed on NRB (a medical device used to prevent hypoxemia - or low blood oxygen - in emergencies.). Oxygen level increased to 96%. Daughter stated Resident #1 suffered a fall two nights ago, which resulted in a femur fracture that was confirmed by an x-ray that was read today. EMS administered Fentanyl for pain .X-ray dated 02/09/23 at 2:52 p.m. showed Displaced fracture (break) involving the right femur (large leg bone). Review of Nurse Progress notes for Resident #1 dated 02/09/23 at 11:44 a.m. showed Resident has a displaced fracture of the right femur of indeterminate age Bony structures are osteoporotic in left hand. No acute fracture or dislocation is identified .Resident stating to have little to no pain. Will continue to monitor further at this time. Bed in lowest position with call light within reach. During an interview on 06/04/23 at 1:10 p.m., Resident #1 said she was being changed by staff, and could not recall the name of the aide, but thinks the aide worked for an agency and not a regular. Resident # 1 said the aide was working alone and there were no other staff helping her. Resident #1 said the aide turned her over to change her and she fell out of the bed and hurt her hand. She said she did not think the aide did it on purpose, but that she just turned her over and she fell off the bed. Resident said she did not feel like she had been abused and felt safe at the facility. Resident said she was not in pain. She said she found out later that she had a crack to her hip. Resident #1 said she was sent to the hospital later because she was having difficulty breathing. During an interview on 06/07/23 at 3:46 p.m., LVN A said on 02/07/23 she was the charge nurse on duty when Resident #1 fell out of bed. LVN A said Resident #1 complained of pain to her left hand after the fall. LVN A said she notified the NP and x-rays were ordered. LVN said later Resident #1 complained of pain to her legs. X-rays were ordered and the results were a fracture to Resident #1's right femur. During an interview on 06/05/23 at 3:19 p.m. CNA B said she had worked at the facility for two weeks. CNA B said she was not sure where to find the level of care a resident required for ADLs. During an observation and interview on 06/05/23 at 3:25 p.m. CNA C said she had worked at the facility since February 2023. CNA C said she would look in PCC to find the level of care for a resident. CNA C attempted three times to demonstrate how to find the level of care in PCC. CNA C was not able to log into the system because her password did not work. During an interview on 06/05/23 at 3:30 p.m. CNA D said she had worked at the facility for about two weeks. CNA D said she would look in PCC to find the level of care for a resident. CNA D said she had just received her password today (06/05/23) and had not yet logged into the system. CNA D said she would just ask the nurse if she had questions about the level of care for a resident. During an interview on 06/05/23 at 3:37 p.m. CNA E said she had worked at the facility for about two months. CNA E said if she did not know the level of care for a resident, she would just ask the nurse. During an interview on 06//05/23 at 3:45 p.m. CNA F said if she had questions about the level of care of a resident, she would look at the physical therapy recommendations book located at the nurse's station, look on PCC or ask the charge nurse. During an interview on 06/05/23 at 3:45 p.m. CNA G said if she had questions about the level of care of a resident, she would look at the physical therapy recommendations book located at the nurse's station, look on PCC or ask the charge nurse. During an interview on 06/07/23 at 3:46 p.m., LVN A said on 02/07/23 she was the charge nurse on duty when Resident #1 fell out of bed. LVN A said Resident #1 complained of pain to her left hand after the fall. LVN A said she notified the NP and x-rays were ordered. LVN said later Resident #1 complained of pain to her legs. X-rays were ordered and the results were a fracture to Resident #1's right femur. During an interview with the Administrator and DON on 06/04/23 at 1:45 p.m. the Administrator said she was not the administrator on 02/07/23 when Resident #1 fell out of the bed and fractured her hip, but the former administrator should have reported the incident and completed an investigation. The Administrator said she was the abuse coordinator. ADM said she could not find any in-service training conducted after the fall on 02/07/23 and the first-time staff were trained on abuse and neglect was 02/24/23. The administrator said she reviewed the QAPI notes for February and March 2023 and could not find where the incident was discussed during the monthly QAPI meetings. The DON said she was the Regional Director of Clinical Operations and currently working as the DON at the facility. DON said, she was not working as the DON on the date of the incident and the incident should have been investigated and reported to the state due to the injury. DON said the agency staff assisting Resident #1, should have been suspended and not allowed to work until after an investigation and staff should have received additional training in reporting abuse/neglect and identifying resident's level of care. During an interview with the Administrator and DON on 06/04/23 at 1:45 PM the Administrator said she was not the administrator on 02/07/23 when Resident #1 fell out of the bed and fractured her hip. The DON said the agency staff assisting Resident #1 should have been suspended and not allowed to work until after the investigation and staff received additional training. The facility was notified of the Immediate Jeopardy on 06/05/23 at 5:20 p.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was submitted by the administrator and accepted on 6/6/23 at 12:50 p.m. and indicated the following: Lindale Specialty, Care Plan of Removal, Updated 6/6/23 Problem: Accidents & Supervision Goal: All staff will be educated on safe handling of residents. After the resident fell out of bed a head-to-toe assessment was completed on 2/07/2023 at 11:07 a.m. by Day shift LVN. Resident complained of pain to her left hand & an x-ray was ordered on 2/07/2023 at 3:04 PM. The results of the x-ray were received on 2/09/2023 at 11:44 AM to the left hand was negative. Results received by Night shift LVN. Resident began to complain to lower extremities. X-ray was ordered on 2/07/2023 at 11:07 AM. The x-ray of the hip was completed, and the x-ray results were received on 2/09/2023 at 11:44 AM by Night Shift LVN. Results revealed a fracture intertrochanteric, was of indeterminate age. The transfer status of the resident was immediately reviewed by the previous DON & changed to a 2-person transfer on the resident's individual plan of care. Significant change MDS was completed by MDS. MDS nurses will be educated on proper coding of resident's ADLs by the Director of Reimbursement on 6/06/2023. All residents' ADL status will be reviewed to ensure it reflects an accurate assessment of the residents' ability. This will be completed 6/06/2023 by 5:00 p.m. by Regional Director of Clinical Services & Director of Clinical Operations. All nursing assistants will be in-serviced on where to look in PCC for transfer status and bed mobility. 50% of the staff have been In-serviced. The in-service will be completed by 6/06/2023. Any staff that missed the mandatory in-service will not be allowed to work until they have been in-serviced. All in-services & education for staff will be completed by the Regional Director of Clinical Operations & the Director of Clinical Operations. All staff will be in-serviced on ensuring that any time a resident requires turning & repositioning in the bed the staff will ensure resident has proper supervision based upon the current care plan. 50% of the staff have been In-serviced. The in-service will be completed by 6/06/2023 at 2:00 PM. Any staff that missed the mandatory in-service will not be allowed to work until they have been in-serviced. All staff will be in-serviced on the Safe Handling policy to ensure understanding to include that the policy states resident lifting & transferring will be performed according to the individuals plan of care. 50% of the staff have been In-serviced. The in-service will be completed by 6/06/2023. Staff will not be allowed to work until they have been in-serviced. All in-services & education for staff will be completed by the Regional Director of Clinical Operations & the Director of Clinical Operations. All CNAs will be educated that any time a resident ADLs decline from what is on the care plan they are to verbally immediately notify the charge nurse. In-service started 6/06/2023 & will be completed at 2:00 PM. Licensed staff will complete a head-to-toe assessment to ensure that any & all changes in residents ADLs will be documented in PCC to ensure changes are reflected in the POC. Additionally, the residents change will be documented on the 24-hour report sheet to ensure that the change is communicated in the morning clinical meeting. In-service started 6/06/2023 and will be completed by end of day. Any staff members that have not received the in-services by end of day will not be allowed to work until it is completed. All in-services & education for staff will be completed by the Regional Director of Clinical Operations & the Director of Clinical Operations. MDS will notify nursing administration immediately both verbally and by email if a resident's transfer or bed mobility status changes. Nursing will notify MDS verbally and immediately if a resident's transfer or bed mobility status changes. Any changes of status with a resident will be reviewed by nursing administration & MDS to ensure that the care plan is updated to reflect the change. This in-service regarding communication of resident status changes will be started today and will be complete by end of day. No staff will be allowed to work prior to being in-serviced. Medical Director was notified of the IJ being called By Regional Director of Clinical Operations. On 06/07/2023 at 2:46 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: 4 LVN's (on all shifts 6 a.m.- 6 p.m. and 6 p.m.- 6 a.m.) 9 CNA's (on all shifts 6 a.m.- 6 p.m. and 6 p.m.- 6 a.m.) said they received training regarding providing ADL care according to a resident's plan of care, where to find the plan of care, who to notify when a resident has a change in condition and documenting it. The nursing staff verbalized understanding of the trainings and said they had access to each resident's plan of care. 2 LVN/MDS Nurses said they received training regarding providing ADL care according to a resident's plan of care, where to find the plan of care, who to notify when a resident has a change in condition, documenting the change of condition and proper MDS coding a resident's ADL status. The Regional Director of Clinical Operations (DON) said she conducted the nursing staff trainings and a review of each resident's ADL status. DON said the review and nursing staff trainings had been completed. On 06/07/23 at 2:46 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to implement interventions based on comprehensive assessments to prevent the worsening of pressure sores for a resident that was admitted with a pressure sore for 1 of 3 resident reviewed for pressure sores (Resident #5.) *The facility failed to ensure treatment orders were present when the resident was admitted with a wound vac on 11/1/22 and 12/16/22. *The facility failed to ensue when the orders for the wound vac were in place before wound vac was discontinued. *The facility failed to provide timely assessments and consistent treatments for a Resident #5 who entered the facility with a stage 4 pressure sore. *The facility failed to provide a low air loss mattress to protect from possible pressure to the area. *The facility failed to provide dietary interventions timely. *They failed to provide nutritional supplemnts timely and as orderd. These failures caused Resident #1's pressure sore to worsen and could cause other Residents to be at risk for a decline in existing pressure sore. Findings included: Record review of Resident # 5's face sheet indicated this [AGE] year-old female was admitted to the facility on [DATE]. Some of her diagnoses were pressure ulcer of sacral region stage 4, pressure ulcer of the right heal stage unspecified, osteomyelitis of the vertebra (infection of the bone), sacral (below the lumbar spine and above the tail bone) and sacrococcygeal (pertains to both the sacrum and coccyx area) region. And another spondylosis with myelopathy ( a nervous system disorder that affects the spinal cord) of the lumbar region. Record review of Resident #5's admission assessment dated [DATE] indicated her skin condition presented with a history of pressure sores, incontinence, poor nutrition, and predisposing diseases. Resident #5's skin integrity indicated she had open areas. The alterations in skin integrity indicated to state the site, type, and measurements. The form indicated there was a pressure sore to the sacral, and right heel with eschar. There were no measurements or stages listed. Record review of Resident #5's (second) Braden scale dated 11/01/22 indicated she was high risk for pressure sores with a score of 10 ( 10-12 high risk). She had very limited sensory perception, was constantly moist, chair fast most of the time, very limited mobility, made occasional slight changes in body or extremity positions. Her nutrition was probably inadequate, rarely ate complete meals. She was at risk for friction or shears. She required moderate to maximum assistance with moving. Record review of Resident #5's physician progress note dated 11/4/22 indicated she was admitted to the facility for skilled services status post initial hospitalization for a right hip fracture. She developed pressure sore on both heels and sacral region. The sacral sore developed into a stage 4 and became infected. She was presented back to the emergency room with metabolic encephalopathy due to infection. She was found severely malnutrition with poor oral intake and dehydration. A magic cup was ordered, and she had a wound vac in pace on her sacral would at this time. Record review of Resident # 5's admission MDS dated [DATE] indicated her cognitive status was moderately impaired. Her functional status was extensive assist of two people for bed mobility and transfer. ( The MDS showed in the system in progress.) Record review of a nutritional risk assessment dated [DATE] indicated Resident #5 weighed 127.8 pounds. Her body mass index was 20. She had an unknown amount of weight loss, and her food intake was less than 50 percent. She would eat by taking only bites and sips. Resident # 5 was independent with eating but required cues. The resident had pressure sore. Resident #5 was at a high nutritional risk currently. She is under weight for her age. She was at a very high risk for addition skin breakdown and weigh loss due to poor by mouth intake. The dietary recommendations were Vitamin C 500 mg two times daily, Zinc 220 mg daily for 14 days, liquid protein daily for 30 days, fortified foods, high calorie snacks three times daily, and house shakes two times daily. The comments were will continue to monitor by mouth intake and weight and skin changes and make additional recommendations as needed. Record review of Weekly Pressure Injury Log dated 11/24/22 indicated Resident #5 was admitted with pressure sore to the sacrum measured 4 measured 4.5cm times 6.4 cm and 2 cm deep. She had one on the heal that was a stage 5 that measured 4.0 times 7.0 that was unable to determine the depth. Record review of her Care Plan last revised on 11/25/22 indicated she had a problem area of impairment of skin integrity. The goal was the resident would maintain or develop clean and intact skin by the next review with a target dated of 12/07/22. Some of the interventions were encourage good nutrition and hydration to promote [NAME] skin. Pressure reliving mattress to bed as ordered. Follow the facility protocols for treatments of injury, keep skin clean and dry. Monitor the dressing as order. Some of the interventions were encourage good nutrition and hydration to promote [NAME] skin. Follow the facility protocols. There was no care plan problem area specific for eating. Record review of Resident #5's a computerized physician orders dated 11/09/22 indicated the following orders: *to cleanse the world to sacral with normal saline and apply calcium alginate, cover with dry dressing every day, and as needed. The revision dated was 11/9/22. *Pressure relieving mattress to bed dated 11/1/22. * a Magic Cup for protein dated 11/14/22, *catheter care dated 11/27/22, *Prostat supplement dated 12/27/22, *vitamin C tablet 500 mg dated 12/27, and *fortified food plan diet, with mechanical soft textures dated 12/27/22. Record review of Resident #5's computerized physician progress note dated 11/11/22 * indicated Resident #5 no longer required the wound vac. Record review of computerized physician orders for the month of November 2022 did not reveal a start order or a discontinue order for the wound vac. Record review of Weekly Pressure Injury Log dated 12/02/22, 12/16/22 and 12/24/22 indicated Resident #5 was admitted with pressure sore to the sacrum and heel with no measurements. The form stated hospital where the measurements were supposed to be. Record review of Resident #5 Census Report( a report used by the facility to document resident admissions and discharges) indicated she was discharged to the hospital on [DATE] and readmitted on [DATE]. Record review of Resident #5's nursing notes indicated she was admitted to the hospital on [DATE] and read readmitted to the facility on [DATE]. Record review of Resident #5's TAR indicated on 12/1/22, 12/2/22, 12/6/22, 12/7/22, 12/24/22 and 12/25/22 the space for the treatment to her sacral wound was blank. The TAR indicated on 12/18 22, 12/19/22, 12/20/22, 12/21/22, 12/22/22, and 12/27/22 indicated other/ progress note. Review of nursing note dated 12/27/22 at 1:57 p.m. indicated the resident refused wound care. Review of nursing notes from 12/18/22 through 12/22/22 did not indicate the resident refused but no wound care was indicated as provided. Record review of Resident #5's weekly skin assessments indicated she had stage 4 since her admission to the facility on [DATE]. There were skin assessments dated 11/8/22, 11/22/22, 12/23/22 and 12/28/22. Record review of Hospital wound care notes dated 12/12/22 indicated wound care follow up for wound vac(a wound vacuum machine can reduce swelling, clean the wound, remove bacteria, help pull the edges of the would together and may stimulate growth) and dressing placement post debridement 12/9/22. Coccyx posterior stage 3 measured 6 cm by 13 cm by 6c deep from 11 to 2 O'clock. Placed 3 pc black foam including offloading for [NAME] pad, good seal achieved at 125mg Hg. Next dressing changed to be completed on 12/14/22. The wound care would continue to follow as scheduled. Reposition patient every two hours using wedges, apply waffle air matters to bed, offloading boots to bilateral lower extremities. Skin moisture for dry skin, apply sacral bordered foam dressing replace three times a week and as needed. Discontinue border foam if frequent incontinence is contaminating wound and use barrier ointment instead bid and as needed. Record review of a skilled care nurses note dated 12/17/22 indicated skin condition, Resident # 5 had a sacrum wound that measured 6.5 cm x 1.5 cm with a 4cm depth stage 4 and wound vac in place. There was no full description of the wound, such as eschar, color, drainage, or odor. Record Review of Resident #5's computerized physician orders indicated there were no new orders for her wound care regarding her readmission on [DATE]. The resident wound orders did not change from 11/9/22. Record review of Resident #5's computerized physician orders indicated: An order for pressure reliving mattress to bed dated 11/1/22, An order for Magic cup every day for protein and caloric malnutrition with a revision date of 11/14/22, An order for skin assessments to be completed weekly and as needed dated 12/23/22, An order dated 12/27/22 for High calorie snacks three times daily, Vitamin C 500 mg, fortified food plan, and House shakes with meals. (Dietician recommended 12/20/22), and An order dated 12/30/22 for Vitamin D3 200 IU by mouth daily dated. There is no order for a wound vac, no order for settings of the wound vac, how often to remove, or when to discontinue the wound vac. Record review of Resident #5's nursing notes dated from 11/4/22 through 12/19/22 indicated: On 11/4/22 at 5:17 p.m. the NP here today making rounds have new order for Magic Cup. On 12/8/22 at 11:30 a.m. Resident #5 was out on pass. On 11/9/22 at 8:43 a.m. Resident #5 was in hospital. On 12/16/22 at 8:30 p.m. Resident back from, the hospital. Infected decubitus ulcer wound is 6.5 cm in length, 14.5 cm wide, and 4 cm in depth. On 12/17/22 at 12:02 a.m. Monitor dressing to sacral every shift for placement and dislodgment, every shift for monitoring wound vac in place. On 12/17/22 at 8:04 p.m. Resident had wound vac in place. On 12/18/22 at 11:59 p.m. indicated the wound vac was in place. On 12/19/22 at 10:24 a.m. sacral cleanse with wound cleanser apply calcium alginate covered with dry dressing every day and as need for dislodgement. Every day shift for Stage 4 wound vac. (note! The notes did not say the wound care was provided. Two of the nurses said they had never proved care to the resident wounds.) Record review of a nutritional risk assessment dated [DATE] indicated Resident #5 weighed 125.6 pounds. Her body mass index was 19. Resident #5 had significant weight loss. Comparison weight on 11/2/22 she weighs 134.6 She her food intake was less than 50 percent. She needed assistance with eating. The resident had pressure sore. Resident #5 was at a high nutritional risk currently. She had increased nutrient needs for wound healing and is underweight with a body mass index of 19. Had significant weight loss, required assistance with meals, and had poor by mouth intake. The dietary recommendations were Vitamin C 500 mg two times daily, Zinc 220 mg daily for 14 days, liquid protein daily for 30 days, fortified foods, high calorie snacks three times daily, and house shakes four times daily (with meals and as bedtime snack). The comments will continue to monitor by mouth intake and weight and skin changes and make additional recommendations as needed. The recomendations were not put into place for 7 days. Record Review of Resident #5's nursing notes dated Indicated: On 12/20/22 at 11:45 a.m. sacral cleanse with wound cleanser apply calcium alginate covered with dry dressing every day and as need for dislodgement. Everyday shift for Stage 4 wound vac. Written by LVN D. On 12/21/22 at 11:06 a.m. sacral cleanse with wound cleanser apply calcium alginate covered with dry dressing every day and as need for dislodgement. Everyday shift for Stage 4 wound vac. Resident had wound vac to sacral wound. written by LVN F 12/22/22 at 4:43 p.m. sacral cleanse with wound cleanser apply calcium alginate covered with dry dressing every day and as need for dislodgement. Everyday shift for Stage 4 wound vac. wound vac in pace. On 12/27/22 at 1:52 a.m. have order for vitamin C 500 g give two by mouth for wound healing. On 12/27/22 at 1:57 p.m. resident refused wound care after two attempts. On 12/28/22 at 4:43 p.m. a family member requested an additional pillow be put in Resident #5'swheelchair. On 12/29/22 at 8:33 a.m. wound care was completed by the 6p to 6a nurse On 12/29/22 at 9:33 a.m. new order received for Vitamin D 2000 IU daily Record review of Resident #5's Braden scale dated 12/29/22 indicated she was high risk for pressure sores [NAME] if 12 ( 10-12 high risk). She had very limited sensory perception, was rarely moist, chair fast most of the time, very limited mobility, made occasional slight changes in body or extremity positions, nutrition was very poor, never ate complete meals. She had a problem with at risk for friction or shears. She required moderate to maximum assistance with moving. During an interview on 12/28/22 at 2:45 p.m. with the Interim DON and Director of Clinical Operations said the said nurses are supposed to write a note or put down why the wound care was not provided. They said former DON had not been diligent in keeping up with her duties. They said the ADON/treatment nurse called on 12/25/22 to say she would not be back. They said they were hiring a new Administrator on Monday. They were looking to hire a new DON, and treatment nurse. They both said the wound vac had been discontinued but could not provide any orders for the wound vac. During a telephone interview on 12/29/22 at 10:18 a.m. the former ADON said she was hired as PRN nurse and eventually took an ADON position. In the beginning she was working as the ADON and the treatment nurse. She said she could not keep up with her administrative duties because she was always pulled to the floor. She said wound care on resdiens and ADON work went by the wayside. She said she was the ADON and wound care she did not have time to keep up with all of her work for constantly being pulled to work the floor. The former staff member said they would have agency staff scheduled to work, but often they did not come. During an observation and interview on 12/29/22 at 11:46 a.m. of Resident #5's room. There was a wound vac noted to be hanging on the right side of the front of the bed rail. LVN C said she worked at the facility for one day and was unaware of the resident having a wound vac. Observation on 12/29/22 at 12:50 p.m. of Resident # 5 showed she was sitting in the dining room feeding herself. She said the food was good. She had mechanical chicken, Pasta, Italian blend vegetables, a biscuit, escalloped peaches, and a drink. There was no shake. She was mostly eating the desert. Review of her lunch slip said she was to have a fortified food plan and a shake. There was no shake. During an interview an observation on 12/29/22 at 12:55 p.m. Dietary manager said Resident #1 was supposed to get a shake with her meal, she did not know why she did not. The resident only ate about 25 percent of what was on her tray. During an interview on 12/29/22 at 2:45 p.m. the Director of Clinical Operations said Resident #5 did not currently have a wound vac. It had been discontinued. She said it was likely hanging on the bed because the agency staff did not know what to do with it. She said she did not know why there was not an order in the chart for the wound vac but would look. She said she could not find a start date or a stop date for Resident #5's wound vac. There was mention of it in the physician progress notes (there was no other information provided.) During observation and interview on 01/05/23 at 2:15 p.m. Resident #5 was sitting up in bed eating. The family member was at the bedside. Resident #5 had chopped ham, whipped sweet potatoes, greens, roll , butter, cake and a beverage. There was no shake on tray. The family member was encouraging Resident #5 to eat. The family member she had not had a shake on resident #5's tray except for last night. The family member said they were present most every night. They were buying Resident #5 ensure themselves to ensure she got more nutrition. Observation showed ensure on a side dresser. During an interview on 01/05/23 at 2:24 p.m. LVN D said today would be the first day doing skin treatment on Resident #5. She did not know if she had a wound vac. The LVN said she thought Resident #5 had a wound vac in the past. No one mentioned it when they told her she needed to complete wound care on the resident. During an observation and interview on 01/5/23 at 4:16 p.m. Resident #5 was noted to be in the bed and her family member was present. LVN D informed the resident she was there to do her wound care on her sacral area. The resident had a worried look on her face and told the nurse it was going to hurt. The nurse reassured the resident and told her she would go slow. LVN D told Resident #5 she be gentle with her treatment so she would not cause her any pain. The resident had a sense of relief on her face and allowed the nurse to conduct her wound care. The resident was turned on her left side by the nurse and a CNA. The nurse removed the sacral wound dressing and measured the resident's wound. The wound had a faint foul odor. The nurse used Dermal Wound Cleanser and sterile 4X4 gauze to clean the wound and repeated it several times. Nurse covered wound with Calcium Alginate pad and secured it with 6 x 7-inch Silicone dressing. Wound measurements: Sacral wound was approximately 15cm (length) x 13 cm (width) the left side was slightly shorter than the right side. The wound extended from the sacral area to her left buttocks. There was a flap of skin at the top of the sacral wound edge from 11 o'clock to 2 o'clock and under that flap the wound tunneled approximately 2cm underneath the skin. Wound appearance: Circular uneven wound edges, wound bed was red, small amount of yellow slough in the middle of the sacral area, small amount of yellow slough at 3 o'clock on the wound edge of the sacral area. The wound showed the full layer of skin and tissue loss with exposed muscle. There was no bone visable. There were no infection control issues noted Resident did not yell out or express any pain during wound treatment and tolerated it well. Staff handled resident in gentle manner. No infection control issues or concerns. Resident #5 said she had no pain during her treatment. She said there were days her wound was more sensitive which caused her pain during wound care. She said the staff handled her in a gentle manner and she was fine. During an interview on 01/05/23 at 4:38 p.m. the interim DON said the Med Aide said they have been giving the boost high calorie said when it pops up on the MAR. The Interim DON said the dietary manger said they had shakes in the kitchen. The Interim DON said she could not find order for Resident #5's wound vac. During an interview on 01/25/23 at 3:49 p.m. agency CNA G said today was her first day working at the facility and she was not familiar with Resident #5. During an interview on 01/05/23 at 4:58 p.m. agency CNA E said today is her first day working in the facility and she was not familiar with Resident #5. During an interview on 01/05/23 at 5:06 p.m. LVN F said she wrote the note on 11/21/22 about the wound vac. She had observed the wound vac on the resident but had not completed wound care. She had never provided care to Resident #5. She said heard another nurse took the wound vac off the that night because there was no order for the wound vac. During an interview on 01/05/23 at 5:42 p.m. the family member of Resident #5 said she had not been on a loss air loss mattress since she was admitted . The family said the facility staff tried to put the wound vac on Resident #5 on 12/29 or 12/30/22 and could not do so. That day the resident had lot of drainage. The family said they did not think the resident got woumd care regulary. They said the wound looked a little better today in regard to the drainage, but it was bigger. During an interview on 01/05/23 at 5:43 a.m. the Interim DON said their procedure was if a resident had multiple stage 3 and stage 4 should qualify for low air loss mattress. Resident #5 had a stage 4 pressure sore. She did not know why Resident #5 was not on a low air loss mattress. During an interview on 01/05/23 at 6:03 p.m. the Director of Clinical Operations said Resident #5's wound vac was discontinued because she has slough in her wound that was why they stopped using the wound vac. She said the NP comes every week. She said all the facility mattresses are pressure reliving mattresses. She could not find the orders for the wound vac and had no explanation of why they were not in Resident #5 records. After reviewing the hospital summary which had no mention of wound care. She said they went by the Hospital Wound Care notes progress notes was where they got the wound vac settings. Record review of the facility Pressure sore policy with an effective date of 04/2022 indicated it is the policy of the facility that a resident who enters the facility without an identified pressure injury not develop and pressure injury unless it is unavoidable. Should a pressure injury develop whether avoidable or unavoidable, the facility will utilize the treatment guidelines below when providing care for the residents. At the time the injury is identified it must be documented on the Skin Assessment Flow Sheet for pressure injury. Pressure sores should be measured weekly and documented. Document the dressing completion on the treatment administration record. As much as possible, the nurse needs to identify the underlying cause as pressure, shear, friction, maceration, or a combination of these factors. Refer the resident for dietary consultation. Document dressing completion on the TAR. Evaluate skin at risk score and update Braden Scale on admission, re-admission, and with any change in condition that might affect skin integrity. The policy indicatated a Stage 4 pressure wound was full- thickness of skin and tissue loss with exposed bone , tendon or muscle,. Slough or eschar may be present on some parts of te wound bed. The wound may also include undermining and tunneling. Record review of a Gravity 8 Deluxe long term care pressure redistribution mattress ( the facility said all their residents have these mattresses.) Indicated it was a high quality therapeutic foam mattress that provided pressure redistribution and shear/ friction reduction. It was high end therapeutic foam mattress that maximizes value and comfort with 3 full layers o latex free foam. The full with top layer used unique die cutting to optimize zoned pressure redistribution.