Every finding on record at Castle Pines Health & Rehabilitation

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for facility's only kitchen reviewed for food storage. The facility did not ensure foods in the refrigerator were stored, labeled and dated when opened or removed from their original packaging on 7/21/2026. The facility did not ensure that expired foods were removed from the refrigerator on 7/21/2026. This failure could place residents who received their meals from the kitchen at risk of food-borne illness.Findings included: During an observation in the facility kitchen on 07/21/26 at 9:50 AM, the refrigerator had the following: *a plastic container labeled peaches with open date of 7/9/2026 and use by date of 7/16/2026. *a plastic bag with multiple sandwiches individually packaged with no date or label on bags. *a container of dark purple, jelly type substance with no open or use by date and not labeled with contents. During an interview on 7/21/26 at 10:00 a.m., the DM said the sandwiches in the refrigerator were made on 7/20/26. She said the sandwiches should have the date made on the outer package. She said the peaches should have been removed from the refrigerator on 7/17/2026. She stated the jelly should have been labeled with contents and date opened and a used by date. Observation of all products removed from refrigerator at the time of the interview. The DM stated all kitchen staff are responsible for labeling and dating foods in the kitchen. She stated kitchen staff is trained to label foods with date opened, use by date and contents. She stated expired foods should be discarded. The DM stated the peaches that were dated with a use by date of 7/16/2026 had not been served after 7/16/2026. She stated she expected all staff to utilize labels for all foods used in the kitchen and for items to be labeled with open date, use by date and contents. She said the risk to residents was serving expired foods and could possibly lead to food-borne illnesses. During an interview on 7/23/2026 at 10:30 am, the Administrator said the Dietary Manager is responsible for monitoring all foods for labeling, expiration, and date of opening. She stated the DM should be making observations of all storage areas daily. She said all kitchen staff are responsible for labeling items after opening with the date opened and use by date. She stated any staff that observed expired items are responsible for disposing expired items. She stated the risk of not dating foods is serving spoiled or out of date foods to the residents that could lead to food borne illness. She said moving forward she expects staff to label all food items with contents and open dates. She said kitchen staff will be expected to dispose of any expired food items. Review of a facility policy titled Food Storage and Supplies, dated 2012, indicated .Open packages of food are stored in closed containers with covers or in sealed bags, and dated as when opened. 9.Perishable items that are refrigerated are dated once opened and used within 7 days.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 12 residents (Residents #23 and #61) reviewed for pharmacy services. 1.The facility failed to ensure OTC medications were not kept at the bedside for Resident #23 on 7/21/2026 and 7/22/2026. 2.The facility failed to ensure a syringe of normal saline 0.9% (a solution used to maintain hydration) was not on a bedside table for Resident #61 on 7/21/2026. These failures could place residents at risk for adverse effects including contamination, tampering, and reduced therapeutic effects of medication. Findings include: 1. Record review of Resident #23's facility face sheet, dated 7/22/2026, indicated Resident #23 was a [AGE] year-old female, admitted [DATE], with a diagnosis of dementia. Record review of Resident #23's quarterly MDS assessment, dated 4/21/2026, revealed a BIMS score of 09 that indicated Resident #23 had moderately impaired cognition. Record review of Resident #23's comprehensive care plan, review date 7/01/2026, indicated Resident #23 had dementia and to administer medications as ordered. Record review of Resident #23's order summary report, dated 7/22/2026, indicated Resident #23 did not have an order to keep medications at bedside and no order for apple cider vinegar gummies nor super reds supplement powder. During an observation on 7/21/2026 at 9:54 am Resident #23 had at her bedside a bottle of OTC medications apple cider vinegar gummies and super reds supplement powder. She said she orders them and she takes them when she feels like it. She said she was not sure if the nurses knew she had them. During an observation on 7/22/2026 at 8:45 am Resident #23 continued to have OTC medications apple cider vinegar gummies and super reds powder on her over bed table. During an interview on 7/22/2026 at 11:12 am CNA C said she was trained to report any medications at the bedside to the nurse. She said she had not noticed the medications in Resident #23's room. She said medications that were not stored correctly could be a risk to the residents. During an interview on 7/22/2026 at 11:16 am LVN D said she worked as a charge nurse at the facility. She said that residents could not keep medications at their bedside unless there was a doctor's order, care plan and they were deemed safe to have them. She said she had not cared for Resident #23, but she should not have any medications in her room. She said medications that were not stored correctly could result in adverse reactions to the residents. During an interview on 7/22/2026 at 11:19 am the ADON said she was working as the nurse on 300 hall where Resident #23 resided. She said she had not seen any medications in the resident's room, but she had a history of ordering medications online and they had to remove them in the past. She said staff should be looking daily during rounds for improperly stored medications and remove them. She said if a resident was keeping and taking medications in their room, it could result in contraindications for them and the other residents. Record review of the warning label for both the apple cider vinegar gummies and super reds supplement powder indicated to keep out of reach of children. 2. Record review of an admission Record for Resident #61 dated 7/21/2026 indicated he was admitted on [DATE] and was [AGE] years old with diagnoses of chronic ulcer to the right heel, hypertensive heart disease (elevated blood pressure in the heart), and diabetes (increased glucose in the blood). Record review of an annual MDS Assessment for Resident #61 dated 6/17/2026 indicated he did have moderate impairment in thinking with a BIMS score of 12. Record review of a care plan for Resident #61 dated 6/17/2026 indicated he was receiving an intravenous antibiotic. Interventions included administering intravenous saline flushes and antibiotic medications as ordered by the physician. Record review of active physician orders for Resident #61 dated 7/21/2026 indicated an order for intravenous antibiotics with saline flushes before and after administration.During an observation and interview on 7/21/2026 at 9:30 am 1 opened 10 milliliter syringe of normal saline 0.9% for intravenous flush was lying on the bedside table with personal care items and a water pitcher. Resident #61 said he was admitted for intravenous antibiotics due to a wound infection in his foot and the nurses must have left the syringe in the room. During an interview on 7/21/2026 at 12:30 pm LVN A said she saw the saline syringe on the bedside table earlier this morning. She said the syringe must have been left at bedside by the night shift. She said she threw it away. She said she would not use a saline flush syringe left at the bedside of a resident because it could be tampered with and not be sterile. She said all medications should be stored and secured appropriately either in the medication room or medication cart. She said that improper storage of medication could affect residents' health. During an interview on 7/22/2026 at 3:30 pm, the ADON said medications should be stored in the medication room and in medication carts and never left at the bedside. She said there could be a risk of other residents going in the room and taking the medication if they were left. During an interview on 7/23/2026 at 9:52 am the DON said that all staff were responsible for checking for improperly stored medications. She said all medications should be properly stored under lock. She said the facility has champion rounds and the administration staff round daily Monday to Friday and medications in the room were to be removed on those rounds. She said she would re-address rounds and what to look for. She said that improperly stored medications and medications left for resident access could result in adverse reactions to the residents. During an interview on 7/23/2026 at 10:32 am, the Administrator said the nurses and unit managers should be checking daily to make sure medications were stored appropriately and should not be left in any resident rooms. She said residents could tamper with the medications if they were left in rooms. Record review of an undated facility policy titled Medication Storage in the Facility indicated, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #107) reviewed for infection control.The facility failed to keep Resident #107's nephrostomy (a catheter inserted through the lower back directly into the kidney to drain urine) drainage bag off the floor on 7/21/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #107 dated 7/22/2026 indicated he readmitted to the facility 7/20/2026 and was [AGE] years old with diagnoses of chronic kidney disease (the gradual and permanent loss of kidney function over time), benign neoplasm of bladder (an abnormal growth that is not cancer), and vascular dementia (a decline in thinking and memory skills caused by a blockage or reduction in blood flow to the brain).Record review of active physician orders dated 7/22/2026 for Resident #107 indicated an order to document left and right nephrostomy output every shift that started on 7/21/2026.Record review of a Quarterly MDS assessment dated [DATE] for Resident #107 indicated he did not have any impairment in thinking with a BIMS score of 13. He did not have an indwelling catheter at that time that included a nephrostomy tube.Record review of a care plan dated 7/21/2026 indicated he had bilateral nephrostomy related to chronic kidney disease. Interventions included checking the tubing for kinks and maintaining the drainage bag off the floor and ensuring the tubing was anchored to the resident's leg or linens. During an observation and interview on 7/21/2026 at 3:15 pm, Resident #107 was in his bed awake with confusion noted. He said he had just been admitted to the facility but did not know what day. He had a nephrostomy drainage bag that was on the right side of the bed on the floor. He said he just had the nephrostomy tubes placed recently.During an observation and interview on 7/21/2026 at 4:05 pm, Resident #107's nephrostomy drainage bag was still on the floor on the right side of bed. LVN E entered the room and answered a call light. LVN E observed the drainage bag on the floor and picked it up and placed it in the bed. She said the bags should be placed in the bed and not on the floor. She said there was a risk of infection control issues if they were on the floor. She said nursing staff were responsible for ensuring the bags were in bed and not on the floor. During an interview on 7/23/2026 at 9:47 am, the IP for the facility said she conducted monthly in-services on infection control with the staff. She said she was made aware of the incident with Resident #107 with the nephrostomy drainage bag being on the floor. She said the drainage bag should not ever be on the floor. She said on 7/21/2026 they implemented drainage bags that were attached with leg straps to the leg, so they were not hanging from the bed. She said all nursing staff were responsible for ensuring the drainage bags were not on the floor as there was a risk of infection control issues. During an interview on 7/23/2026 at 9:58 am, the DON said she had been at the facility for 7 weeks and the IP was responsible for training staff on infection control. She said the facility conducts infection control training monthly. She said she was made aware of the drainage bag of Resident #107 being on the floor on 7/21/2026 and that day they implemented securement devices and attached the bags to his legs. She said the nurses were responsible for checking the drainage bags and they should never be on the floor as there was a risk of infections. She said she planned to re-educate the staff. She said they conducted an in-service on how the drainage bags should be stored. Record review of a facility in-service date 7/21/2026 indicated the staff were training on infection control that included nephrostomy tubes could not be placed on the floor. During an interview on 7/23/2026 at 10:10 am, the Administrator said the clinical team that included the DON, ADONs, and the IP for the facility were responsible for training staff on infection control that was done monthly and as needed. She said drainage bags should not be placed on the floor. She said any staff that made rounds that saw the bags on the floor should make sure they were picked up. She said there was a risk of infection control issues if the bags were on the floor or they might not drain properly. She said they planned on continued education on infection control measures and to ensure staff made sure the bags were attached properly.Record review of a facility policy undated titled Catheter Care indicated, .10. Be sure the catheter tubing and drainage bag are kept off the floor Record review of a facility policy undated titled Nephrostomy indicated, .7. Secure the drainage bag to calf, thigh, or waist with tape or straps .

Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food prepared in form designed to meet individual needs for 1 of 5 residents (Resident #1) reviewed for dietary services. The facility failed to follow a mechanical soft diet order on 7/6/26 at approximately 5:40 p.m. when facility staff served Resident #1 a chopped corndog causing Resident #1 to choke. Resident #1 expired in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 7/9/26 at 2:45 p.m. The noncompliance was identified as PNC. The past noncompliance began on 7/6/26 and ended on 7/8/26. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk of choking, hospitalization, and death.Findings include: 1. Record review of the face sheet dated 7/8/26 indicated Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including end stage renal disease (kidney failure), major depressive disorder, atherosclerotic heart disease (narrowing and hardening of arteries due to plaque buildup), type 2 diabetes, and muscle wasting and atrophy (loss of muscle tissue from disuse). Record review of a quarterly MDS dated [DATE] indicated Resident #1 had a BIMS of 11 which indicated moderately impaired cognition. He was independent with eating and was not on a therapeutic diet at the time. Record review of the care plan dated 6/29/26 indicated Resident #1 had an actual choking episode during medication pass. Interventions were put in place including asking the resident not to eat anything that was not in his diet. Record review of a therapy screen dated 7/3/26 at 1:45 p.m. indicated Resident #1 exhibited a change in swallowing/choking/weight loss/decreased PO intake. A Description of the change indicated Resident #1 presented with increased choking with solids and liquids as well as a recent pneumonia diagnosis. Speech therapy was recommended by the SLP. Record review of an order summary dated 7/8/26 indicated Resident #1 was ordered a mechanical soft texture diet, nectar consistency, on 7/3/26. Record review of the care plan dated 7/6/26 indicated Resident #1 had a diet order other than regular (regular mechanical soft with nectar thicken liquid). Record review of an event note for a choking episode dated 7/6/26 at 5:50 p.m. indicated Resident #1 choked in his room. The nursing description of the event indicated to see progress note. Initial treatment performed included the Heimlich maneuver and CPR, and 911 was called. Review of a nursing progress note dated 7/6/26 at 5:45 p.m. by LVN B indicated at approximately 1740 (5:40 p.m.) FM of patient called facility to inform that patient was choking. This nurse ran to room checked mouth and found to be empty. FM stated she had already swept his mouth. Patient still breathing. Radial pulse 57 manually (checked on the radial artery), attempted Heimlich maneuver with one thrust but was unsuccessful. Turned pt around to find pt blue. This nurse checked apical pulse (checked by listening to heart's anatomical apex with a stethoscope with no pulse present, pt eyes rolled back. This nurse alerted others of code blue and began CPR compressions. 911 called. Other nurses and staff entered room and assisted in CPR until EMS arrived. Record review of an eTransfer Form dated 7/6/26 at 6:00 p.m. indicated Resident #1 was transferred to the hospital on 7/6/26 at 6:00 p.m. The reason for transfer was listed as unresponsive. Record review of a Record of Death dated 7/6/26 indicated Resident #1 was admitted to the hospital on [DATE] at 6:07 p.m. and was pronounced dead at 6:13 p.m. The diagnosis and immediate cause of death was listed as cardiopulmonary arrest. Review of Resident #1's progress note dated 7/7/26 at 12:52 a.m. indicated the on call NP and MD were notified of Resident #1 being sent to ER for choking. The resident expired at hospital. Review of a witness statement by [NAME] A indicated she worked on 7/6/26 and prepared the dinner meal of corndogs, tater tots, and cucumber tomato salad. For mechanical soft meals green beans were to be served as an alternate in place of the salad. [NAME] A indicated there was a misunderstanding between chopped and ground preparations. [NAME] A indicated she had been educated now and knew the difference. [NAME] A indicated she did not ground up the corndogs for mechanical soft diets; she chopped them with a knife. During an interview on 7/8/26 at 12:30 p.m., LVN C said she was doing wound care for another resident when she heard someone call a code blue in room [ROOM NUMBER]. LVN C said she went to the nurses' station and got the AED then ran down to room [ROOM NUMBER]. LVN C said when she got there Resident #1 was lying on his bed on his back and staff were doing chest compressions. LVN C said the resident was nonresponsive when she arrived. LVN C said another nurse had arrived with the emergency cart containing a backboard During an interview on 7/8/26 at 1:20 p.m., LVN B said she was working on hall 200 and 100 on 7/6/26. LVN B said the phone rang at the nurse's station and Resident #1's family member asked staff to come to his room as he was choking. LVN B said when she arrived at the room, she checked resident's mouth and didn't see anything she could remove but said there was definitely something lodged in resident's throat. LVN B said she was able to attempt the Heimlich maneuver, performing one-thrust, at which point she noted the resident was turning blue and was nonresponsive. LVN B said she quickly checked for a pulse and noted none then called for a code blue (medical emergency) and began CPR. LVN B said she continued compressions until she was relieved by LVN C who continued compressions until EMS arrived. During an interview on 7/8/26 at 1:55 p.m., [NAME] E said residents with therapeutic diets were identified by their dietary cards which were printed by the DM every shift. [NAME] E said the cooks and dietary aides followed the dietary cards when preparing trays. [NAME] E said mechanical soft meat should be ground, prepared in the grinder/chopper until it was a small and ground texture. [NAME] E said a chopped diet would be prepared by cutting the food into small bite-sized pieces. During an interview on 7/8/26 at 2:04 p.m., LVN B said on 7/6/26 she assisted LVN D with checking resident trays on 7/6/26 for the evening meal service. LVN B said her responsibility was to ensure the trays coming out of the kitchen were correct as compared to the dietary binder and dietary card. LVN B said all except for 2 of the mechanical soft diet recipients were served chopped corndogs for dinner that day. LVN B said Resident #1 was not served a ground diet, he was served a chopped corndog. LVN B said she did question the kitchen as to whether or not the meals were correct and was told the DM said the preparation was appropriate. During an interview on 7/8/26 at 2:15 p.m., the DM said resident diets were identified through tray cards which she printed daily. The DM said the tray card identified the correct diet to be served to the resident and were followed by the cooks and dietary aides when preparing trays. The DM said both she and nursing staff were responsible for checking trays to verify each tray was correct and matched the dietary card. The DM said on 7/6/26 she left early for a personal reason and was not there to check the trays. The DM said kitchen staff were in-serviced on food textures for therapeutic diets and liquid thickeners before and after the incident and [NAME] A had been full trained, there was just a misunderstanding in their communication that day The DM said the proper way to prepare mechanically soft meat was to use the chopper machine to chop the food up into small pieces like ground meat. The DM said she usually added broth to add moisture to the food while chopping. During an interview on 7/8/26 at 2:45 p.m., the DON said resident diet orders were printed and put into a binder. The DON said a nurse was assigned daily to check the trays and ensure each tray matched the diet card. The DON said she believed the incident occurred due to there being a need for more education of nursing staff on therapeutic diets. The DON said a nurse was assigned, by hallway, to check the trays as they were coming from the kitchen and making sure the dietary cards matched. The DON said all staff would receive training in textures and thickened liquids. The DON said she had already begun in-servicing staff and no staff member would be able to work until they had completed the in-services. The DON said ongoing monitoring was taking place in the form of interviewing nursing staff weekly to ask about choking related information, how to identify residents who needed assistance, and how to respond to a choking resident. The DON said department heads were also in-serviced and would be taking turns ensuring the nursing staff was checking the trays in the kitchen for texture and consistency. During an interview on 7/8/26 at 3:00 p.m., [NAME] A said she worked on 7/6/26 and cooked dinner at the facility. [NAME] A said the DM told her to chop up the corndogs for the mechanical soft diet, which she interpreted to chop with a knife. [NAME] A said she had since been re-educated that mechanical soft diet meat should be chopped to a ground texture. [NAME] A said the incident occurred because she had only been employed at the facility for 2 weeks and was not aware of the differences in therapeutic diets. During an interview on 7/8/26 at 3:45 p.m., LVN D said a nurse was assigned to check the meal trays as they came out of the kitchen every meal; assigned by hallway. LVN D said the nurse was responsible for checking the dietary book and matching the information to the dietary card and the tray, ensuring the appropriate diet had been served. LVN D said on 7/6/26 she was assigned to check the trays and checked trays for halls 300 (Resident #1's hall), 400, and 500. LVN D said all the corndogs that were served to mechanical soft residents were chopped up into circles. LVN D said she questioned the kitchen about the chopped corndogs and kitchen staff were adamant that it was correct. LVN D said she had since been re-educated on and understood the difference between mechanical soft and chopped diets. During an interview on 7/8/26 at 4:05 p.m., the SLP said on 7/3/26 she changed Resident #1's diet from a regular diet and texture to a mechanical soft texture due to the resident's issues with coughing and choking while eating. The SLP said the resident's dietwas changed on 7/3/26 and she sat with him on 7/6/26 during the lunch service to evaluate the change. The SLP said the resident had no issues and did not choke or cough during the meal. The SLP said the resident did have poor safety awareness (taking large bites) and she worked with him with alternating liquids and solids and cueing. The SLP said mechanical soft food meant ground meat moistened with a gravy or broth. During an interview on 7/9/26 at 10:40 a.m., the RD said Resident #1 was initially on a regular diet and had just recently switched to a mechanical soft diet. The RD said mechanical soft meat portions should be prepared by grinding the meat in a blender or food processor. The RD said any meat for mechanical soft diets should be ground. The RD said a mechanical chopped diet meant the food was prepared in bite-sized pieces. The RD said she had not previously noted any concerns with therapeutic textures or thickened liquids in facility. The RD said the risk of a resident being served a chopped diet when ordered a mechanical soft diet could be the resident choking. During an interview on 7/9/26 at 3:05 p.m., the ADM said all staff had been in-serviced or would be in-serviced on textures and thickened liquids among other topics. The ADM said the DM checked the trays in the kitchen and the assigned nurse checked the trays again once they left the kitchen. The ADM said in the event of the DM being unavailable, the cook would check the trays. The ADM said department heads were in-serviced, as well as all staff, on all topics including food texture orders, thickened liquids, and choking and aspiration(inhalation of foreign material into the airways or lungs). The ADM was able to identify a mechanical soft diet versus a chopped diet and how to compare meal trays to the dietary binder to ensure correct meals had been served. Review of an undated facility policy titled Recommended Diets indicated .Mechanical Soft Diet.This diet is designed for persons with chewing or swallowing difficulty. In addition to minced and moist meat or flaked fish served in sauce or gravy, with an average particle size of approximately 4mm in width and less than 15mm in length.The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on 7/9/26 at 2:45 p.m. The facility took the following actions to correct the non-compliance: Review of the Self-Reporting Protocol/Ad Hoc (when necessary) QAPI - Choking meeting indicated the following corrective actions were taken: -Complete entry into risk management for choking incident and complete choking event note. Attempt to determine the root cause of the resident choking.-Took statements from all staff involved or with potential knowledge/involvement-Assessed all residents that are ordered a diet other than regular for any signs of symptoms of aspiration or choking during the last meal service. -CPR certifications for all nurses were audited.-Verified Heimlich maneuver poster is in dining room.-Picture description sheet added to dietary nurse binder for tray checks. -All families e-mailed to notify a charge nurse immediately if they bring in outside food to a resident.-Updated resident care plan-All resident charts were audited for physician ordered or care planned interventions to ensure they are in place-The DON and/or ADON will review all residents for potential swallowing problems and refer to the ST-The DON and/or ADON and DM will reconcile all resident diet orders to ensure that the correct physician ordered diets are entered into the dietary tray card system. Review of the Choking Monitoring log indicated nursing staff were being interviewed weekly with 8 of 10 interviews completed as of 7/9/26 for the week. No choking events were identified during incident/event reviews. The DON and/or ADON will monitor at least 10 meals each week to ensure trays are being checked for consistency by a nurse prior to presenting to the resident and that all residents who required supervision while eating were being supervised by staff. Monitoring had been completed for 7 of 10 meals as of 7/9/26 for the week. Record review of an in-service titled Choking / Aspiration dated 7/6/26 indicated the ADM attended a 1-on-1 in-service. Record review of an in-service titled Choking / Aspiration dated 7/6/26 indicated he DON attended a 1-on-1 in-service. Record review of an in-service titled Choking / Aspiration dated 7/6/26 indicated ADON F attended a 1-on-1 in-service. Record review of an in-service titled Choking / Aspiration dated 7/6/26 indicated ADON G attended a 1-on-1 in-service. Record review of an in-service titled Choking / Aspiration dated 7/6/26 indicated the DM attended a 1-on-1 in-service. Record review of an n-service titled Choking / Aspiration dated 7/6/26 indicated 57 staff members of various disciplines attended the in-service. Record review of an in-service titled Choking / Aspiration dated 7/7/26 indicated 19 staff members of various disciplines attended the in-service. Record review of an in-service titled Choking / Aspiration dated 7/8/26 indicated 3 staff members of various disciplines attended the in-service. Record review of an in-service titled CPR dated 7/6/26 indicated 2 staff members attended the in-service, including the ADM. Record review of an in-service titled CPR dated 7/6/26 indicated the DON attended a 1-on-1 in-service. Record review of an in-service titled CPR dated 7/6/26 indicated ADON F attended a 1-on-1 in-service. Record review of an in-service titled CPR dated 7/6/26 indicated ADON G attended a 1-on-1 in-service. Record review of an in-service titled CPR dated 7/6/26 indicated the DM attended a 1-on-1 in-service. Record review of an in-service titled CPR dated 7/6/26 indicated the in-service was attended by 57 staff members of various discipilines. Record review of an in-service titled CPR dated 7/7/26 indicated the in-service was attended by 19 staff members of various discipilines. Record review of an in-service titled Thicken Liquids dated 7/6/26 was attended by 4 staff members including the ADM. Record review of an in-service titled Thicken Liquids dated 7/6/26 indicated the DON attended a 1-on-1 in-service. Record review of an in-service titled Thicken Liquids dated 7/6/26 indicated ADON F attended a 1-on-1 in-service. Record review of an in-service titled Thicken Liquids dated 7/6/26 indicated ADON G attended a 1-on-1 in-service. Record review of an in-service titled Thicken Liquids dated 7/6/26 indicated the DM attended a 1-on-1 in-service. Record review of an in-service titled Thicken Liquids dated 7/6/26 indicated 24 staff of various disciplines attended the in-service. Record review of an in-service titled Thicken Liquids dated 7/7/26 indicated 48 staff of various disciplines attended the in-service. Record review of an in-service titled Textured/Modified Diet/Following MD orders dated 7/6/26 indicated the ADM attended a 1-on-1 in-service. Record review of an in-service titled Textured/Modified Diet/Following MD orders dated 7/6/26 indicated the DON attended a 1-on-1 in-service. Record review of an in-service titled Textured/Modified Diet/Following MD orders dated 7/6/26 indicated ADON F attended a 1-on-1 in-service. Record review of an in-service titled Textured/Modified Diet/Following MD orders dated 7/6/26 indicated ADON G attended a 1-on-1 in-service. Record review of an in-service titled Textured/Modified Diet/Following MD orders dated 7/6/26 indicated the DM attended a 1-on-1 in-service. Record review of an in-service titled Textured/Modified Diet/Following MD orders dated 7/6/26 indicated 38 staff of various disciplines attended the in-service. Record review of an in-service titled Textured/Modified Diet/Following MD orders dated 7/7/26 indicated 41 staff of various disciplines attended the in-service. Record review of in-service titled Kardex (quick-reference summary tool that condenses essential patient information into a single, portable format so nurses can access it at a glance during care delivery )dated 7/7/26 indicated 28 staff members of various disciplines attended the in-service. Record review of in-service titled Only use menu driven Meal Tickets. dated 7/6/26 was attended by the DM and [NAME] A. Record review of in-service titled Only use menu driven Meal Tickets. dated 7/7/26 revealed the in-service was attended by 8 dietary staff members. Record review of in-service titled All meat must be put in Robo [NAME] for Mechanical dated 7/7/27-7/8/26 revealed the in-service was attended by 8 dietary staff members. Review of the Dietary Training Inventory dated 7/7/26 indicated [NAME] A was retrained in all curriculum. Review of the Order Listing Report dated 7/7/26 indicated residents with therapeutic mechanical diets were audited to identify any concerns with diet orders. No new concerns were noted. Record review of an undated Mechanical Soft Texture Guide picture sheet indicated samples of foods allowed for different diet textures including puree and mechanical soft textures. During an observation on 7/8/26 at approximately 12:00 p.m. revealed a Heimlich maneuver instructional poster was hung in the dining room. During an observation on 7/8/26 at 12:05 p.m., revealed the department heads including the DM and ADM were observed in the dining room supervising to ensure a nurse was checking trays against the dietary binder and dietary card. Resident trays sampled for mechanical soft diet had an appropriate meal texture served for 4 of 4 residents sampled. The Heimlich maneuver poster was hung in the dining room. During an observation on 7/9/26 at 11:58 a.m., the meal service was observed in the kitchen. Trays were prepared according to dietary cards and matched correctly for 4 of 4 sampled residents. During interviews with staff members on 7/8/26 and 7/9/26 at various times between 2:50 p.m. and 3:05 p.m. indicated the ADM, CNA H, CNA I, Med Aid J, LVN K, LVN L, Med Aid M, Housekeeper N, CNA O, AD, Med Aid P, LVN Q, LVN R, CNA S were all able to explain what a mechanical soft texture diet was and it's purpose. All staff interviewed were able to explain the signs and symptoms of a resident who needed dining assistance or who may be experiencing a choking episode and how to respond. On 7/9/26 at 2:45 p.m., the ADM was informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 7/6/26 and ended on 7/08/26. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 1 (Resident #1) resident reviewed for supervision. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 3/23/26 when he walked out the front door of the facility.The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 3/23/26 and ended on 3/24/26. The facility corrected the non-compliance before surveyor's entrance.This failure could place residents at risk of not being properly supervised resulting in injury or death.Findings included: Record review of the electronic face sheet indicated Resident #1 was a [AGE] year old male originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnosis that included: malignant neoplasm of the brain (brain cancer), hyper lipidemia (high cholesterol), seizures, carcinoma (cancer) in bronchus and lung, nicotine dependance, depressive disorder, and hypertension (high blood pressure). Resident was also receiving Hospice care. Record review of Resident #1's admission MDS assessment dated [DATE] indicated a BIMS of 00, which indicated severe cognitive impairment with inattention and disorganized thinking. The MDS also indicated Resident #1 had no wandering behavior. Record review of Resident #1's care plan dated 12/29/25 indicated the following: - Resident #1 had impaired cognitive function or impaired thought processes. Interventions included: Administer meds as ordered, communicate with the resident/family/caregivers) regarding residents capabilities and needs, Discuss concerns about confusion, disease process, NH placement, with the resident/family/caregivers. -Resident #1 was at risk for wandering. Interventions included: assess for fall risk, distract resident from wandering by offering diversions, structured activities, food, conversations, identify patterns of wandering: is it purposeful, aimless or escapist. Record review of Resident #1's care plan dated 3/23/26 indicated the following: -Resident #1 was at risk for elopement as evidenced by resident is ambulatory and has altered mental status at times. Interventions included: Resident placed on 1:1 for actual elopement, seek alternate placement for secured unit. Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 20 which was of high risk category.Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 20 which was of high risk category.Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 19 which was of high risk category. Record review of an event note dated 3/23/26 and signed off by LVN M indicated Resident #1 exited out the front door, was gone 20 minutes and found at the apartment complex next to the facility. Resident #1 reported he was going to his mom's house. Cognition/behavior at the time of the event: cognitive impairment, wanders, exit seeking. Nurse description of the event: this nurse was notified by other charge nurse that she thought she saw the Resident walking near the road while she was outside on break. This nurse initiated a search of the Resident's room and did not find him. Officers arrived to the facility in response to a call from the Resident. Elopement protocol initiated and a search of the facility and immediate ground was completed. The Resident was located and returned to the facility immediately by officers. Initial treatment and or new orders was one on one monitoring. Nurse Practitioner and responsible party notified. All exit doors were checked for proper functioning and all found to be in working order.Record review of an Elopement and Risk Assessment Report indicated risk assessments were initiated on 3/24/26 on all residents. Record review of the timeline dated 3/23/26 provided by the DON of camera footage revealed the following:6:12 p.m. LVN L went outside,6:22 p.m. Resident #1 seen leaving the facility,6:25 p.m. LVN L returned to the facility,6:31 p.m. staff members noted to go outside,6:34 p.m. police entered facility, and6:55 p.m. Resident returned to facility with police. During an observation on 5/13/26 at 9:05 a.m., the front entrance door to the facility had a large green sign on the inside and outside that said: All Visitors-Please do not allow residents to exit the building unless it is your family member and you have notified staff. During an interview on 5/13/26 11:50 a.m., the DON stated Resident #1 was standing at the front doors looking out around 6:22 p.m. on 3/23/26. Stated a female visitor punched the code to enter, and Resident #1 held the door open for and went out after she came in. The DON stated around 6:12 p.m. LVN L had gone outside on a smoke break and saw a man come out of the facility walking across the grass but could not tell who it was but thought it was Resident #1 . After talking with other staff, and a search in the facility, it was determined to be him. The DON stated Resident #1 left the building around 6:22 p.m. on 3/23/26, and when the facility called the police they were told they had already been notified by Resident #1 who told them the facility was holding him hostage. Staff drove over to the apartment complex next door and located Resident #1 who would not return to the facility with them. Resident #1 said he went to visit his sister (who had previously lived there for 9 years, and Resident #1 and his mother would visit her). Resident #1 told the police he was not going back because they were holding him hostage. Police finally talked him into coming back after about 10 minutes. The DON stated the police arrived around 6:45 p.m. to the Resident's location and returned to the facility at 6:55 p.m. The DON stated Resident #1 did not have dementia but had a brain tumor and had never attempted to elope prior to this incident. Stated all exit door alarms were checked and found in working order, Resident #1 was placed on 1:1 and transferred to another facility the next day. The DON stated on the elopement risk assessments, anything over a score of 10 triggered for high risk and there had not be any other elopements in the facility. During an interview on 5/13/26 at 1:00 p.m., the Administrator said that on 3/23/26, the resident made the choice to go visit his sister who had lived in the apartment complex next door to them. Stated after the incident a sign was placed on the inside and outside of the entrance door in bright green that said: All Visitors-Please do not allow residents to exit the building unless it is your family member and you have notified staff. The Administrator said they did not admit residents felt to be flight risks. Stated Resident #1 had not attempted to get out of the facility before this incident. Stated if they noticed any patterns of exit seeking with a resident, or if a resident says they are going to leave the facility they would have a care plan meeting to look at alternate placement. Administrator stated Resident #1 was steady on his feet, and you couldn't really tell he was a resident most of the time. Stated Resident #1 had a friend that came to the facility and would take Resident #1 out to smoke in his vehicle off the premises, as smoking was not allowed. Stated the nurse who went out to smoke the day of the incident, was on the other side of the facility premises and was not sure if it was Resident #1 she saw walking in the grass or not as it was quite a ways away. On the date of the incident, Administrator stated Resident #1 exited the facility when a visitor and punched the key code in and opened the door. Stated as she opened the door, he held it for her and when she came in, he went out. Stated inservice training was initiated after the incident, and Resident was placed 1:1 until he was transferred out the next day. Stated all door alarms were checked and in working order and elopement risk assessments done on all residents. During an interview on 5/13/26 at 1:20 p.m., CNA C stated she had taken care of Resident #1 while he was on 1:1 monitoring, and that he was sweet and non-combative. Stated he had good days and bad days with his memory. Stated Resident #1 told her that he had cancer, and it had spread all over. Stated Resident #1 would walk around the facility quite a bit, and the only time she had seen him wanting to leave was when his sister was leaving and he wanted to go with her. CNA C stated the sister would take him out on pass at times. Stated she had never seen him try to go out any of the doors. Said his gait was usually fairly stable. Stated he would walk to the dining room for meals and was friendly to everyone. CNA C stated Resident #1 told her that his sister lived in the apartments next door and he was trying to go visit her. During an interview on 5/13/26 1:32 p.m., MA A stated she had never seen Resident #1 go to an exit door or try to get out. Stated Resident #1 would go to the dining room and back to his room, and his gait was steady when she had observed him. MA A stated Resident #1's sister would come get him and take him on outings once in a while, but he usually stayed in his room or was in the dining room. MA A stated she had never seen him go to the door unless he was going out with his sister. During an interview on 5/13/26 at 1:36 p.m., CNA D stated Resident #1 always wanted to go home with his sister, and the sister would take him out once in a while, otherwise he would stay in his room most of the time. CNA D stated Resident #1 would get up and go to the dining room or go get coffee, but she had never seen him just wander around the halls. CNA D stated some days Resident #1's memory was good, other days it was a little off. During an interview on 5/13/26 at 1:44 p.m., LVN L stated on the day of the incident, she had gone outside on break about 6:10-6:15 p.m. Stated she went to the end of the facility property line by the trees to smoke and she saw someone walking across the facility grass. Stated she thought it looked like Resident #1 but was not 100% sure, and the person was walking fast, and it was quite a distance from where she was. Stated she immediately came back to the facility and notified the other staff working. Stated the police arrived shortly after she came back in before they could even call them. Stated the police told them that Resident #1 had called them. Stated she did not remember what they said as to what Resident #1 told them when he called. Stated she did not know what transpired after the police talked to the staff, but Resident #1 was brought back to the facility. LVN L stated she had never seen Resident #1 try to get out of the facility before. During an interview on 5/13/26 at 1:59 p.m., LVN P stated she was working the day of the incident with Resident #1. Stated around 6:30ish, LVN L, the nurse on hall 500 came to her and another nurse. LVN P stated she thought she saw someone who looked like Resident #1 walk outside while smoking. LVN P stated both nurse aides and med aides looked for Resident #1. LVN P stated the police had showed up at the facility at that time. Police had asked if he had been found. Staff told them what happened and they all went to the apartment building next to the facility. LVN P stated that around 15-20 minutes later police came back with Resident #1. LVN P stated she thought Resident #1 was gone for about 20 minutes. LVN P stated she had never seen Resident #1 try to get out or even asked to get out. Stated Resident#1 was alert and oriented x 3 with intermittent confusion. LVN P stated it was about 5 minutes after they found out about the incident that the police came. During an interview on 5/13/26 at 2:23 p.m., LVN Q stated Resident #1 had been admitted to the facility prior. Stated on both admits his BIMS scores were 0 due to inattention, and disorganized thinking. Stated Resident #1 had never tried to get out of the facility that she knew of prior to this. Stated he was care planned for wondering, which he did walk around the halls aimlessly at times, but never attempted to elope. During an interview on 5/14/26 at 12:20 p.m., the DON stated there had not been any indications that Resident #1 would go out the door. Stated Resident #1 did not show any signs of exit seeking and had not voiced any concerns that he wanted to leave or go home. Stated he did nothing to make us think he was going anywhere. The DON stated Resident #1 engaged and interacted with the staff appropriately. The DON stated all families/responsible parties were contacted by email or phone call asking them to not allow residents to exit the building unless it was their family member and they had notified the staff or phone call on 3/24/26. During an interview on 5/14/26 at 1:28 p.m., ADON O stated she felt staff acted appropriately when they found Resident #1 was missing. Stated inservice training was started immediately after the incident, and elopement risks were done on all residents. During an interview on 5/14/26 at 1:34 p.m., the Administrator said she felt the facility had done everything they could to protect Resident #1, and everything was put into place; the documentation, the assessments, new interventions, and they followed all their protocols to ensure residents are not exit seeking by doing elopement assessments on all residents, and moving Resident #1 to an environment suited for him. During an interview on 5/14/26 at 1:41 p.m., ADON N stated she had helped with staff education after the incident. Stated they would hide residents who were willing to participate, and the staff had to follow procedure till they were found. Stated the staff were very receptive to the education. Record review of a facility policy titled Elopement Response with a revision date of 1.2026 revealed the following: .nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred the elopement response plan will be immediately implemented.should an employee discover the resident is missing from the facility they should: report to charge nurse, make a thorough search of the building and premises. The interventions and plan for correction included: 1. Record review of a Discharge Summary for Resident #1 dated 3/24/2026 indicated he discharged from the facility on 3/24/2026 to another nursing facility.2. Record review of an event nurses' note dated 3/23/2026 at 6:30 pm by LVN M indicated Resident #1 Hood eloped from the facility and was placed on 1:1 monitoring. All exit doors checked for proper functioning. All found to be in working order.3. Record review of elopement risk assessments for the facility dated 5/14/2026 indicated all 95 residents in the facility had elopement risk assessments that were completed on 3/24/2026 with the exception of new admissions that were completed on their admission dates after 3/24/2026.4. Record review of family notifications dated 3/24/2026 by the BOM Assistant indicated an email was sent to the RP's that stated, Please do not allow residents to exit the building unless it is your family member and you have notified staff.5. Record review of 1:1 in-services on elopement prevention, elopement response and abuse/neglect was provided to the DON and Administrator by the Regional Nurse.6. Record review of Medical Director notification of the immediate jeopardy citation was on 5/13/2026.7. Record review of an Ad Hoc QAPI meeting was held on 5/13/2026 to discuss an identified immediate jeopardy related to accidents and supervision.8. Record review of an inservice dated 3/23/2026 on elopement response by the DON indicated 91 staff were in attendance of the training and the training was ongoing as of 5/14/2026.Record review of an inservice dated 3/23/2026 on if you see a resident elope what to do by the DON indicated 88 staff were in attendance of the training and training was ongoing as of 5/14/2026.Record review of an inservice dated 3/23/2026 on abuse/neglect by the DON indicated 86 staff were in attendance of the training and training was ongoing as of 5/14/2026.Record review of an inservice dated 3/23/2026 on resident rights by the DON indicated 100 staff in attendance of the training.Record review of an inservice elopement prevention, abuse/neglect and resident rights for new hires after 3/24/2026 by ADON N and ADON O indicated 13 staff in attendance of the training from 3/25/2026 to 5/1/2026.During an observation on 5/14/2026 at 9:15 am, signage at front door for visitors to ask staff prior to letting any residents out. Front door locked and sign indicated to press button to get into the facility.During a phone interview on 5/14/2026 at 10:57 am, RP of Resident #5 said she was made aware of the signage at the front entrance to not let residents out without staff knowledge.During an interview on 5/14/2026 at 11:20 am, the RP of Resident #6 said he visited daily. He said he was contacted about a month ago about not letting residents out with him when he left. He said this morning when he arrived he had to push the button for them to let him in the facility.Attempted a phone interview on 5/14/2026 at 11:30 am, the RP of Resident #7 was unable to leave a voicemail message due to the mailbox being full.Record review of a progress note dated 3/24/2026 at 11:04 am, by the ADON N to the RP of Resident #7 indicated .Called emergency contact at this time to inform them to please not open the door or let anybody out of any of our exit doors to keep our resident's safe. Ensure that if they are taking any residents out to sign them out and let the charge nurse know beforehand. During interviews on 5/14/2026 from 11:36 am to 1:47 pm staff from different shifts included: CNA B, CNA C, CNA D, DOR, LVN E, PT, HSK F, DA G, LVN L, and LVN P: staff were able to verbalize if saw a resident that was trying to leave the facility and would intervene and try to turn them around and let the nurse know and get the resident to safety. If a resident was wandering and trying to go to the door would redirect them. They verbalized if a resident was missing, report a code orange, would notify the charge nurse and start looking inside and outside of the facility; if outside and did not want to go back in the would stay with them and call someone to come. They verbalized in their POC and care plan it would show them the residents who were high risk for elopement. If the residents were a high risk, they had to make sure they did not wander off or get close to the door. They all verbalized the abuse coordinator was the Administrator. If they observed any abuse/neglect would report immediately to the Administrator. They verbalized visitors and families had to push a button at the front entrance to be allowed in and no one could enter the facility unless staff let them in. They verbalized they conducted elopement drills in the facility. During an observation on 5/14/26 at 1:04 p.m., environmental rounds were made with the maintenance supervisor. The following door alarms were found to be in compliance and alarmed when opened: front entrance door, exit doors on halls 200, 300, 400, 500, and 2 doors in the therapy department. Alarms were able to be heard at the opposite end of each hall. Record review of Resident #1's electronic medical record indicated Resident #1 discharged from the facility on 3/24/26. On 5/13/26 at 5:32 p.m., the Administrator and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 3/23/26 and ended on 3/24/26. The facility had corrected the noncompliance before the investigation began.

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 6 sampled residents (Resident #24 and Resident #44) and one of one dining rooms reviewed for environment. The facility failed to ensure the dining room was without excessive noise levels during meals for Resident #24, Resident #44 and other residents in the dining room. This failure could place residents at risk for diminished quality of life due to the lack of an enjoyable dining experience. Findings included: Record review of Resident #24's face sheet, dated 05/19/2025, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe enough to interfere with daily life), Chronic obstructive pulmonary disease also known as COPD (a common lung disease causing restricted airflow and breathing problems), and high blood pressure. Record review of Resident #24's quarterly MDS assessment, dated 05/08/20/25, indicated Resident #24 usually understood and was usually understood by others. The MDS assessment indicated she had a BIMS score of 13 indicating she was cognitively intact. Record review of Resident #44's face sheet, dated 05/1920/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included obesity, lack of coordination, and difficulty walking. Record review of Resident #44's quarterly MDS assessment, dated 04/0120/25, indicated Resident #44 usually understood and was usually understood by others. The MDS assessment indicated she had a BIMS score of 15 indicating she was cognitively intact. During an interview on 05/18/2025 at 10:15 AM, Resident #24 said the staff are too loud in the dining room and it makes the whole experience not enjoyable. Resident #24 said the staff just talk too loudly, especially in the evening. Resident #24 said the noise was so loud that she can't enjoy eating in the only dining room in the facility. During an observation on 05/18/2025 at 12:30, PM, of the lunch meal, the television was on in the dining room and very loud, residents and staff were talking loudly to be able to hear each other. This surveyor had to bend down near Resident #24 ear to be able to hold a conversation with her. Resident #24 stated see what I am talking about, all this noise and the evening meal is worse when no administrative staff are here. During an interview on 05/18/2025 at 10:30 AM, Resident #44 said the noise is the dining room was a problem at the facility. Resident #44 said we have talked about this in our council meetings. Resident 44 said the noise level would get better but would return to a level so loud everyone was shouting. She said the meal gets ruined by the staff being so loud. During an interview on 5/20/2025 at 11:00 AM, the Activity Director said the dining room noise has been a problem off and on. She said the loud noise level could decrease dining enjoyment and distract residents while eating. During an interview on 5/20/2025 at 11:30 AM, the Administrator said that not controlling the noise in the dining room could result in a decreased dining experience. She said the facility would in-service staff and acquire signage to remind staff to turn off the television before dining times and be aware of noise in the surroundings. Record review of resident advisory council minutes dated August 2024 revealed under nutrition services review, meal service concerns: Residents stated that staff are extremely loud in the dining room. Record review of resident advisory council minutes dated December 2024 revealed under nutrition services review, meal service concerns: Residents stated that staff are too noisy in the dining room. Record review of resident advisory council minutes dated April 2025 revealed under concerns: During church services two CNAs came through the dining room talking loudly. Record review of facility resident rights policy from the Social Services [NAME] 2003, revised 11/28/2016 indicated, The resident has a right to be treated with respect and dignity .The resident has the right to a safe environment - The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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 the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure the dietary manager, dietary aide and cook effectively wore a hair net to cover all hair. 2. The facility failed to ensure foods stored in the refrigerator and freezer were labeled and dated. 3. The facility failed to ensure foods stored in the pantry were sealed or in a sealed container. These failures could place residents at risk of foodborne illness and food contamination. Findings Include: During an observation on 05/18/2025 at 9:45am and on 05/19/2025 at 11:25, the DM, DA-G, DA-H and [NAME] had hair from under hair covering on the front, sides, and backs of their heads. During an observation on 05/18/2025 between 9:55am-10:25am, the following undated, unlabeled, and unsealed items were identified by Cook-F in the freezer, Refrigerator, and pantry: REFRIGERATOR: *1-bowel tomato soup, no date or label *1-bowel apple sauce, no date or label *1-bowel chicken soup, no date or label FREEZER: *1-gallon bag of chicken, no date or label *1-large bag of French fries, no date or label *3-large pork shoulders, no date or label *1-gallon package of taco meat, no date or label *1-10-inch apple pie, no date or label PANTRY: *1-4-ounce bag of semi-sweet chocolate chips were open not sealed or in a sealed container. *1-12-ounce box of tea bags were open not sealed or in a sealed container. : During an interview on 5/19/2025 at 3:35pm with DA -E, she said hair nets should be worn to keep hair from getting into food and to be sanitary. She said hair in the resident's food could make them angry or upset and make someone ill due to bacteria exposure. She said labeling and storing should happen as soon as possible when food arrives at the facility. She said if the food is not labeled, someone may not know what the item is and could serve the wrong food to the wrong person. She said the chance of a resident getting ill increases with non-labeled and improperly stored food. During an interview on 5/19/2025 at 3:46pm with DM , she said hair nets are to be worn and cover all hair so no-hair gets into the food. She said hair in the food could be a choking hazard for residents. She said if hair gets into food, it's instantly contaminated. She said chemicals or products on an employee's hair could cause a negative reaction to residents. She said labeling and dating food items should happen as soon as possible when it comes off the delivery truck. She said when food is opened staff should add the open and expiration date and make sure it is sealed properly. During an interview on 5/19/2025 at 4:10pm cook-K said hair nets keep hair out of food. She said hair in the food could cause choking, spread germs and bacteria to the residents. She said labeling and dating, should happen when food first comes into the kitchen. She said dating and labeling protects residents from receiving the wrong foods or out of date foods that could cause them to become ill. During an interview on 5/19/2025 at 11:45am with DA-G, she said hair nets should be worn all the time when in the kitchen. She said all hair should always be covered to keep food from being unsuitable to serve. She said resident could become ill and or upset from having hair in their food. She said foods should be labeled and dated shortly after it's delivered to the facility. She said food items may be out of date and no one will know and use old food if not dated. She said if not labeled some food items cannot be identified and may be served to the wrong resident causing them to be sick. During an interview on 5/19/2025 at 10:30am with DA-H She said hair nets should be always worn when in the kitchen and should cover all the staff's hair. She said hair could get in the food and contaminate the food. She said hair in the food could cause residents to get sick. She said all foods should be dated and labeled as soon as it arrives in the kitchen. She said dating and labeling helps identify food, know when it came into the facility and when it expires. She said if not properly dated and labeled expired or wrong foods could be served to the residents and cause sickness to the residents. During an interview on 5/19/2025 at 4:00pm, with the Administrator she said the kitchen staff should wear a hair net or covering that covers all their hair when in the kitchen. Said hair could easily get in the food causing bacteria/germs to contaminate the food. She said the residents can become ill or have a reaction to hair being in their food. She said all food should be date and labeled when in the kitchen. She said no dates or labels can cause food to be expired and staff would not recognize it and cause to wrong food to be served to the wrong resident. She some residents have allergies to certain foods and if it's not labeled, they could easily get the wrong food and become ill. She said expired foods could also make residents sick. During an interview on 5/19/2025 at 03:50pm, with the DON she said all food must be dated and labeled when entering the kitchen to assure food can be identified and no expired foods are left in the kitchen. She said not labeling correctly can cause a resident to receive the wrong food type and cause an allergic reaction or become ill. She said no date can expose residents to expired foods and cause illness. During an interview on 5/19/2025 at 3:30, with the ADON, she said all food in the kitchen should be dated and always labeled. She said all staff should be using good hand hygiene. She said all kitchen staff's hair should be always covered. She said hair could get in the food and cause contamination. Said all residents are at risk of becoming ill if the staff do not use good hand hygiene, store, and label food appropriately or keep food at appropriate temperatures. Record review of a Dietary Services Policy & Procedure Manual 2012 titled Food Storage and Supplies reads Procedure: 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Record review of the Food and Drug Code dated 2022 indicated: 3-602 Labeling 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement. 3-201.11 Compliance with Food Law. (C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 13 residents (Resident #41 and Resident #196) and 6 of 9 staff (CNA A, CNA B, CNA O, CNA P, CNA Q, and LVN R) reviewed for infection control. 1.The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions and performed hand hygiene when providing incontinent care to Resident #41 on 5/18/2025. 2.The facility failed to ensure CNA O performed hand hygiene between passing resident trays on 5/18/25. 3.The facility failed to ensure CNA P and CNA Q followed enhanced barrier precautions and performed hand hygiene when providing incontinent care to Resident #196 on 5/19/25. 4.The facility failed to ensure LVN R performed hand hygiene after removing non-sterile gloves and donning sterile gloves for a procedure for Resident #196 on 5/19/25. These failures could place residents at risk for cross contamination and infection. Findings included: 1. Record review of Resident # 41's facility face sheet revealed Resident #41 was a [AGE] year-old male and admitted on [DATE] with diagnosis of multiple sclerosis (disease that affects the central nervous system). Record review of Resident 41's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderately impaired cognition, relied on staff for all ADL's, was incontinent of bowel and bladder, and required a feeding tube. Record review of Resident #41's comprehensive care plan dated 4/10/2024 revealed Resident #41 was on enhanced barrier precautions (an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs)) and gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed, mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. During an observation on 05/18/25 at 3:17 pm Resident #41 had a sign on his door indicating he required EBP and there was PPE outside his room in a cart. During an observation on 5/18/25 at 3:20 pm CNA A and CNA B entered Resident #41's room to provide incontinent care. Both CNAs washed their hands and applied gloves but neither applied a gown per the EBP guidelines. During incontinent care neither CNA performed hand hygiene between glove changes and neither performed hand hygiene before leaving the room. During an interview on 5/18/25 at 3:30 pm CNA A said she had been trained on EBP and hand hygiene. She said Resident #41 had a feeding tube and wound and she should have put on a gown as well as gloves for his care but forgot. She said she should have washed or sanitized her hands between glove changes and before leaving the resident's room. She said by not following infection control measures infections could spread. During an interview on 5/18/25 at 3:32 pm CNA B said she had been trained on EBP and hand hygiene. She said Resident #41 had a feeding tube and a wound and she should have put on a gown as well as gloves for his care. She said she got nervous and forgot. She said she should have washed or sanitized her hands between glove changes and before leaving the resident's room. She said by not following infection control measures infections could spread. 2. During an observation on 5/18/25 at 12:50 pm CNA O was observed passing meal trays to residents. She was observed to pass a tray to a resident in their room, exit room, and without sanitizing or washing her hands, served the next room their meal tray. During an interview on 5/18/25 at 12:55 pm CNA O said she did not know she was supposed to sanitize or wash her hands between serving meal trays. She said she guessed it could be because of the risk of cross-contamination. During an interview on 5/20/25 at 10:19 am Administrator said she expected her staff to wash or sanitize their hands between passing resident's trays. She said it could cause cross-contamination. She said the facility would be holding a hand hygiene clinic to educate all staff on hand hygiene to ensure compliance going forward. 3. Record review of a facility face sheet dated 5/19/25 for Resident #196 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of discitis, unspecified, lumbosacral region (inflammation and infection of the space between vertebrae). Resident #196 had not been in facility long enough to have an MDS assessment completed. Record review of a comprehensive care plan dated 5/17/25 for Resident #196 indicated that she required enhanced barrier precautions with the following interventions: .Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity . and .Perform hand sanitation before entering the room and prior to leaving the room . and .Posting at the residents room entrance indicating the resident is on enhanced barrier precautions . During an observation on 5/19/25 at 9:00 am CNA P and CNA Q were observed to enter Resident #196's room to provide incontinent care. Neither one washed their hands upon entering room nor did they wear appropriate PPE for EBP. After CNA Q provided incontinent care to Resident #196, she did not change gloves before putting a clean brief on resident. During an interview on 5/19/25 at 9:20 am CNA P and CNA Q said they forgot to wash their hands when entering room and CNA Q said she forgot to change gloves before applying a clean brief. Both said they were not aware that Resident #196 required EBP. They both said improper hand hygiene and not changing gloves could cause residents to be at risk for infections. 4.During an observation on 5/19/25 at 12:06 pm LVN R was observed providing a PICC line dressing change on Resident #196. She was observed to apply non-sterile gloves to remove old dressing. After removing old dressing, she removed her non-sterile gloves and applied her sterile gloves without washing or sanitizing hands. During an interview on 5/19/25 at 12:20 pm LVN R said she did not wash or sanitize her hands after removing non-sterile gloves and putting sterile gloves on. She said it could put the resident at risk of cross-contamination. She said she just forgot to wash or sanitize her hands before putting her sterile gloves on. During an interview on 5/20/25 at 9:30 am the ADON said she was also the infection preventionist and was responsible for the oversight of staff following the infection control program. She said all staff were trained on infection control on hire, annually and throughout the year. She said she did observations with the staff for their competency check offs and at random. She said that staff not following the infection control program could cause the spread of infections and expected all staff to follow proper EBP, hand hygiene and follow all the appropriate steps for the infection control program. During an interview on 5/20/25 at 9:35 am the Regional Nurse Consultant said that all staff should be following the infection control program daily and had been trained on hire, annually and throughout the year. She said staff that don't follow the infection control guidelines for hand hygiene and EBP could spread infections and expected staff to follow the guidelines the facility had in place. During an interview on 5/20/25 at 9:55 am the Administrator said the infection preventionist and the DON were responsible for the oversight that all staff were following the infection control program. She said they were to make random daily rounds to ensure staff were compliant with following hand hygiene, EBP and any other infection control task. She said she expected the staff to always follow the infection control program to prevent the spread of infections. Record review of a CNA proficiency audit dated 11/19/24 revealed CNA B had been trained on hand washing and infection control measures. Record review of a CNA proficiency audit dated 12/05/24 revealed CNA A had been trained on hand washing and infection control measures. Record review of a CNA proficiency audit dated 10/12/24 revealed CNA O had been trained on hand washing and infection control measures. Record review of a CNA proficiency audit dated 4/21/25 revealed CNA P had been trained on hand washing and infection control measures. Record review of a CNA proficiency audit dated 3/13/25 revealed CNA Q had been trained on hand washing and infection control measures. Record review of a Licensed Nurse Proficiency audit dated 11/19/24 revealed LVN R had been trained on hand washing and infection control measures. Record review of facility policy titled Enhanced Barrier Precautions dated 4/01/2024 indicated, .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities . Record review of an undated facility document titled Hand Hygiene revealed, .you may use alcohol-based hand cleaner or soap/water for the following: after removing gloves . Record review of a facility policy titled Perineal Care dated 4/27/2022 revealed, .start 11) don (put on) gloves and all other PPE per standard precautions, 24) doff (take off) gloves and PPE, 25) perform hand hygiene .

Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 5 of 5 residents who were reviewed for immunizations (Resident #24, Resident #25, Resident #44, Resident #49 and Resident #89). The facility failed to document, in Resident #24, Resident #25, Resident #44, Resident #49 and Resident #89 medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: Record review of Resident #24's face sheet, dated 05/19/2025, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe enough to interfere with daily life), Chronic obstructive pulmonary disease also known as COPD (a common lung disease causing restricted airflow and breathing problems), and high blood pressure. Record review of Resident #24's quarterly MDS assessment, dated 05/08/2025, indicated Resident #24 usually understood and was usually understood by others. The MDS assessment indicated she had a BIMS score of 13 indicating she was cognitively intact. Review of a document titled, immunization audit report dated 5/20/2025, revealed Resident #24 and/or her representative was offered the Sars-Cov-2 vaccine on 01/0820/24 and refused. The document indicated no other offer of covid vaccination, and no education given. Record review of a facility face sheet dated 05/20/2025 for Resident #25 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses Alzheimer's disease (inability to remember and cognitive decline) and hypertension (high blood pressure). Record review of Resident #25's quarterly MDS assessment, dated 04/24/2025, indicated she had a BIMS score of 7 indicating she had severe cognitive impairment. Review of a document titled, immunization audit report dated 5/20/2025, revealed Resident #25 and/or her representative was not offered the Sars-Cov-2 vaccine on admission and the document indicated no education given. Record review of Resident #44's face sheet, dated 05/19/2025, indicated a [AGE] year-old female who was admitted initially to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included obesity, lack of coordination, and difficulty walking. Record review of Resident #44's quarterly MDS assessment, dated 04/01/2025, indicated Resident #44 usually understood and was usually understood by others. The MDS assessment indicated she had a BIMS score of 15 indicating she was cognitively intact. Review of a document titled, immunization audit report dated 5/20/2025, revealed Resident #44 had a historical Sars-Cov-2 vaccine on 7/05/2021 and no documentation that resident #44 was offered the Sars-Cov-2 vaccine on admission and readmission. The document indicated no other offer and no education given on covid vaccination since she has lived at the facility. During an interview on 05/20/2025 at 10:22 AM, Resident #44 said she did not remember receiving education on covid vaccines or the facility offering her a covid vaccine. She said she had taken a covid vaccination about three years ago when the vaccine first was developed. Resident # 44 said she might be interested in the covid vaccine if offered. She said she had not received written education on the covid vaccines risks or benefits. Record review of a facility face sheet dated 5/20/2025 for Resident #49 indicated that she was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses including: urinary tract infection, pain in shoulders, and reduced mobility. Record review of Resident #49's quarterly MDS assessment, dated 04/01/2025, indicated Resident #49 usually understood and was usually understood by others. The MDS assessment indicated she had a BIMS score of 11 indicating she had mild cognitive impairment. Review of a document titled, immunization audit report dated 5/20/2025, revealed Resident #49 and/or her representative was offered the Sars-Cov-2 vaccine on 01/08/2024 with no education given and she refused. The document indicated no other offer, or no education given for covid vaccination. Record review of a facility face sheet dated 5/14/2025 for Resident #89 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: myocardial infarction (heart attack), urinary tract infection, and muscle weakness. Record review of Resident #89's quarterly MDS assessment, dated 02/26/2025, indicated Resident #89 usually understood and was usually understood by others. The MDS assessment indicated she had a BIMS score of 13 indicating she was cognitively intact. Review of a document titled, immunization audit report dated 5/20/2025, revealed Resident #89 and/or her representative was not offered the Sars-Cov-2 vaccine on admission and the document indicated no education given. During an interview on 5/20/2025 at 11:00 AM, the Regional Nurse Consultant said the facility had no consent form for covid vaccination or declination to be used when the resident or representative refused vaccinations. She said it was the policy of the facility to document immunization administration or refusals in the electronic medical record and document education given under the education tab. The Regional Consultant said it was the policy of the facility to offer covid vaccination on admission and as needed. The Regional Nurse Consultant said the DON would be responsible going forward to ensure that residents were educated on immunizations and documentation. She said residents could be at risk of not knowing what they were refusing if they were not provided education on covid vaccines. During an interview on 5/20/2025 at 11:15 am, the Administrator said the DON was responsible for immunizations and going forward residents will be provided education regarding benefits and risks. She said that residents and families could possibly not have the knowledge to make informed decisions concerning covid vaccinations if risks and benefits were not provided. Record Review of Covid Response Plan revised 5/08/2023 indicated . COVID-19 Vaccination: Residents and staff will be provided education regarding Covid-19 vaccines upon hire or admission and as needed afterward.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 residents (Resident #23) reviewed for resident rights. The facility failed to ensure the best friend did not speak degradingly to Resident #23 while attempting to assist with personal care on 5/19/25. These failures placed residents at risk of decreased feelings of self-worth and decreased quality of life. Findings include: Record review of facility face sheet dated 5/19/2025 indicated Resident #23 was a [AGE] year-old female admitted to the facility 8/9/24. Diagnosis included encephalopathy (a group of conditions that cause brain dysfunction), convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles), and profound intellectual disabilities (the inability to live independently, being in need of close supervision, limited communication, and physical restrictions). Record review of quarterly MDS dated [DATE] indicated that a BIMS score was not determined due to the resident's inability to speak or participate in the assessment. Resident required total assistance with all ADL's. During an observation on 5/19/25 at 8:50 AM, while standing in the hallway, a female adult was heard saying, Get over here. We need to brush your hair, get over here. in a loud and degrading tone. Observation revealed a female standing at the foot of Resident 23's bed with a hairbrush in her right hand. Unable to visualize the resident due to the wall. Observed female reaching across towards the head of the bed with the brush approximately 4 times and saying, Come her. in a degrading tone. Upon entering the room, noted the female with the brush was a best friend. Resident #23 was lying in bed positioned up toward the head of the bed and against the wall. No visual injuries noted. Resident unable to communicate verbally but smiled and reached out to surveyor as the bed was approached. The best friend then stated, She is curled up in that bed trying to keep from getting her hair brushed. When exiting the room, noted the best friend went to the foot of the bed and was reaching to brush the resident's hair. During an interview with the social worker on 5/20/25 at 8:20 AM, she stated that she has not had any reports of disrespectful or degrading behavior by any visitors or staff. She stated the best friend's program is determined during a resident's PASRR evaluation. She stated the program is ran by an outside source. She stated a supervisor will come and do observations of the best friends in the building to monitor interactions. She was unable to recall the last visit made by the supervisor. She stated best friends is a companion program and that all training is done prior to individuals being assigned to a resident. She said any complaints would be reported to the administrator and the program director. During an interview with the administrator on 5/20/25 at 8:35 AM, she stated that she has not witnessed any degrading behaviors by any visitors, or the best friends assigned to the facility. She stated staff has not reported any incidents to her. She said she is the abuse coordinator and that all concerns are reported to her. She stated she has not had any complaints related to the best friend's program. She said she would be responsible for investigating any reports of degrading behaviors that occur in the facility. An interview with the best friend was not obtained. She left the building immediately following the incident. Record review of facility resident rights policy from the Social Services [NAME] 2003, revised 11/28/2016 indicated, The resident has a right to be treated with respect and dignity.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #348) reviewed for medication storage. The facility did not ensure a medication named Digestive Enzymes was not stored at the bedside for Resident #348 on 05/18/2025. This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: Record review of facility face sheet dated 05/18/2025 indicated Resident # 348 were an [AGE] year-old female admitted to facility on 05/10/2025 with diagnosis of Wedge Compression Fracture of T7-T8 Vertebra, Subsequent encounter with routine healing. Record Review of comprehensive care plan dated 05/10/2025 did not indicate Resident # 348 could keep medication at bed side or safely self-administer medications. The care plan reflects to administer medications as ordered. Record review of admission MDS dated [DATE] indicated Resident # 348 had a BIMS of 13 indicating intact cognition. Record review of consolidated physician orders dated 05/18/2025 indicated Resident #348 did not have an order for Digestive Enzymes. During an observation and interview on 05/18/2025 at 10:40 am Resident # 348 was observed with medication on her nightstand. She stated she self-administer the medication (digestive enzymes) every night for nausea. During an interview on 5/20/2025 at 9:10am with LVN-N she said no resident should have medications at their bedside. She said she did not know of any residents having medications in their rooms. She said a physician's order must be on file for the resident to receive the medication as well as to self-administer medications. She said a resident could take inappropriate amounts of the medication or another resident could wonder in the room and get the medication and take it. She said residents could have an allergic reaction or become ill from taking unprescribed medication. During an interview on 5/20/2025 at 9:40am CNA-M said no resident should have medications at bedside. She said the resident could have a negative reaction to the medication such as elevated B/P or other allergic reactions. During an interview on 5/20/2025 at 9:18am CMA-L She said she's not aware of any resident having medications in their room. She said a resident can make themselves sick by taking unprescribed medications. She said all medications must have a physician's order and be given by a nurse or medication aide. During an interview on 5/20/2025 at 9:25am CMA-D said no resident should have medications at bedside. She said the resident could have a negative reaction to the medication such as elevated B/P or other allergic reactions. During an interview 5/19/2025 at 3:05pm with DON She said no resident should have medication of any kind at their bedside. She said the medication must be ordered by a physician's prior to administering and should be administered by a nurse or medication aide. She said another resident could go in the room and take the medication. She said any medication no ordered by the physician could cause an adverse reaction to any resident. During an interview on 5/10/2025 at 3:30pm ADON said no medication at bedside has been reported to her. She said residents are care planned to have medications in their rooms. She said resident could become ill or other residents could wonder in the room and get the medication and make them sick as well. She said all medication needs a physician's order and be administered by a nurse or a med aide. During an interview on 5/19/2025 AT 4:00PM with the administrator she said she was not aware of any residents having medications left in their room. She said no residents in the facility are care planned or have orders to have medications in their room and all medications should be administered by a nurse or medication aide and must have a physician's order. She said residents could cause altercation to their prescribed medications by altering the effects of the prescribed medications, causing labs and levels to be off and putting other residents in the facility to be ask risk of unnecessary medication intake. She said another resident could wonder into the room and get the medication, take it and cause harm to themselves. Record Review of Pharmacy Policy & Procedure Manual 2003 titled Bedside storage of medications indicated, 1. A written order for the bedside storage of medication is placed in the resident's medical record. Record Review of Pharmacy Policy & Procedure Manual 2003 titled Bedside storage of medications indicated, 10. All nurses and aides are required to report to the charge nurse on duty any mediations found at the bedside not unauthorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary.

Based on interviews and record reviews, the facility failed to ensure that residents were free of significant medication errors for 1 (Resident #1) of 3 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when Resident #1 was administered another resident's medications, Glatiramer Acetate (medication to treat multiple sclerosis) by LVN A on 1/6/2025. The noncompliance was identified as PNC. The noncompliance began on 1/6/2025 and ended on 1/8/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician. Findings included: Record review of Resident #1's admission Record, dated 3/11/2025, reflected Resident #1 was a [AGE] year-old male. He was initially admitted on [DATE] and readmitted on [DATE]. He was noted to have diagnoses including symptoms and signs involving the musculoskeletal system, unspecified protein calorie malnutrition (lack of protein and calories), hypertension (high blood pressure), and dementia (decline in cognitive abilities such as memory and problem solving). Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1's BIMS score was 00 indicating Resident #1's cognition was severely impaired. His medication was documented to include anticoagulant (medication to treat and prevent blood clots), and antidepressant (medication to treat depression). Record review of Resident #1's Care Plan, dated 10/9/2024, reflected Resident #1 had impaired cognitive functional dementia or impaired thought processes with interventions that included: Administer medications as ordered. Resident #1 had hypertension with interventions that included: Give anti-hypertensive medications as ordered. Record review of Resident #1's Physician's orders dated 1/6/2025 indicated Resident #1 did not have an order to administer Glatiramer Acetate (medication used to treat multiple sclerosis). Record review of Resident #1's nursing progress notes dated 1/6/2025 at 10:00am written by LVN B indicated Resident #1's family member was concerned about medication for multiple sclerosis being given to Resident #1 because she was unaware that he had that diagnosis. Upon investigation of this concern, it was determined that a medication error had occurred. Resident #1's physician was notified and an order to monitor residents' vital signs and assess for side effects of the medication was received. Record review of Resident #1's nursing progress notes dated 1/6/2025 at 12:47pm written by LVN A indicated Resident #1 was transferred to the hospital related to Resident #1 received the wrong medication and Resident #1's requested the transfer for further monitoring. Record review of Resident #1's nursing progress notes dated 1/6/2025 at 12:57pm written by LVN A indicated Resident #1 received the wrong medication (glatiramer acetate 40mg/ml) that morning at 8:00am. Resident #1 had been monitored since and had shown no adverse reactions. Resident #1's vital signs were blood pressure 104/57 (normal is less than 120/80), pulse 71 (normal 60-100), temperature 97.7 (normal 97-99). Resident #1's lungs were clear on both sides, rise and fall of chest was equal. Injection site showed no signs of redness or irritation. Resident #1's pupils were equal and reactive. Resident #1 was conscious and responsive. Resident #1's strength was equal to upper and lower extremities. Resident #1's requested Resident #1 be sent to the hospital . Record review of Event Nurses' Note dated 1/6/2025 written by LVN B indicated . 5. Nursing description of the event: was concerned about medication for multiple sclerosis being given to Resident #1 because she was unaware that he had that diagnosis. Upon investigation of this concern, it was determined that a medication error had occurred. 17. One on one in servicing with nurse for medication error, Monitoring of the patient, all nursing staff in serviced on medication administration. Record review of Discharge -Summary V4 dated 1/6/2025 at 3:00pm indicated: A. Reason for discharge: Resident went to the hospital and chose to go to another facility after discharge from the hospital. Record review of hospital paperwork dated 1/6/2025 indicated No likely effect from Glatiramer Acetate use. During an interview on 3:10pm at 2:54pm LVN A said she had been off of work for a couple of weeks and when she came back to work there were 2 residents with similar names that were next door to each other. She said she went to give Resident #1 the injection he lifted his shirt as if he had always received the medication so she administered the medication. She said Resident #1's was there and asked what she had given him and when she told the said she was not aware that Resident #1 was diagnosed with multiple sclerosis. She said upon investigation of the diagnosis of multiple sclerosis it was determined that a medication error had occurred. She said she notified the DON, and ADON immediately. LVN A said Resident #1's requested Resident #1 be sent to the hospital for monitoring. She said after the incident she was in serviced regarding medication administration and was put with a preceptor for a few days following the incident. Record review of facility Licensed Nurse Proficiency Audit dated 11/19/2024 indicated: LVN A had shown to be satisfactory with administering medications properly. Record review of facility policy Medication Administration Procedures revised 10/25/2017 indicated: 4. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. Record review of Ad Hoc QAPI dated 1/6/2025 regarding medication error with attendees that included: Administrator, DON, ADON, Medical Director, Social Services, Regional Clinical Nurse, and the Area Director of Operations. Record review of Inservice titled Medication Administration dated 1/6/2025 and 1/7/2025 signed by LVN A. Record review of Inservice titled Resident Rights dated 1/7/2025 signed by LVN A. Record review of Inservice titled Medication Not Available dated 1/7/2025 signed by LVN A. Record review of Inservice titled 7 Rights of Medication dated 1/7/2025 signed by LVN A. Record review of Inservice titled Medication Error dated 1/7/2025 signed by LVN A. Record review of Inservice titled Abuse/Neglect dated 1/7/2025 signed by LVN A. Record review of Inservice titled Resident Rights dated 1/7/2025 signed by all staff. Record review of Inservice titled Abuse/Neglect dated 1/7/2025 signed by all staff. Record review of Inservice titled Medication Administration dated 1/7/2025 signed by nurses and medication aides. Record review of Inservice titled Medication Not Available dated 1/7/2025 signed by nurses and medication aides. Record review of Inservice titled Medication Error dated 1/7/2025 signed by nurses and medication aides. Record review of Inservice titled 7 Rights of Medication dated 1/7/2025 signed by nurses and medication aides. Record review of Licensed Nurse Proficiency Audit prior to the incident dated 11/19/2024 and after the incident dated 1/7/2025. During interviews 3/10/2025 at 3:13 pm through 3/11/2025 10:06am the following nurses and medication aides were able to properly describe the medication administration procedure and the 7 rights of medication administration, what to do if medication is not available, what to do in case of a medication error, and abuse and neglect: LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, MA G, MA H, MA J, LVN K, RN L, LVN M, LVN O. The noncompliance was identified as PNC. The noncompliance began on 1/6/2025 and ended on 1/8/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #13) reviewed for accidents and hazards. The facility failed to ensure Resident #13 was provided with adequate supervision to prevent her from falling off the mechanical lift of the facility van on 02/28/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/28/24 and ended on 03/05/24. The facility corrected the non-compliance before survey began. This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols. Findings included: Record review of Resident #13's Face sheet undated revealed she was admitted to the facility on [DATE]. Resident #13 was a [AGE] year-old female admitted with diagnosis of anemia (low red blood cells), end stage renal disease (kidneys cease to function), dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working). Record review of Resident #13's significant change in status MDS assessment dated [DATE] revealed she had a BIMS score of 13 indicating no cognitive impairment. The MDS Assessment indicated Resident #13 was dependent with chair/bed-to-chair transfers. The MDS Assessment indicated Resident #13's car transfer was not attempted. Record review of Resident #13's care plan dated 12/22/2023 and revised on 02/12/2024 revealed: Resident #13 was at risk for falls related to impaired mobility, incontinent status with interventions that included Mechanical lift x2 to assist with transfers. Resident #13 has limited physical mobility related to generalized weakness with interventions that included The resident requires x1 staff participation for mobility and the resident uses wheelchair for locomotion. Record review of incident report dated 02/28/2024 revealed: nurse was called outside to the facility van resident was lying on right side on ground just behind van. Head to toe assessment done resident was assisted back in the w/c and brought into building. 14. Initial treatment/New orders revealed: assessment done sent to hospital for further evaluation. 15. Resident Statement revealed: I tipped over backwards and fell . Record review of the facility's Provider Investigation report dated 02/28/2024 revealed the following: [Resident#13] was being unloaded in the van using the lift. The seatbelt came unfastened and [Resident #13's] wheelchair tipted backwards causing [Resident #13 to fall backward hitting her head on the pavement. No bruising cuts, abrasions were noted. [Resident #13] complained of head pain. V/S WNL, pupils reactive, [Resident #13] was alert and oriented x4. [Resident #13] was sent to ER via ambulance. Record review of hospital medical records dated 3/1/24 revealed Resident #13 was transferred from local hospital to higher level of care hospital via helicopter on 2/28/24 with multiple trauma injuries: right subdural hematoma with 3mm leftward shift, T1 (first bone in the spinal column) acute compression fracture and T4 (fourth bone of the spinal column) acute compression fracture. During an interview on 03/24/24 at 10:38 AM Resident # 13 said she was returning from dialysis on 02/28/2024 when Van Driver D pulled into the facility and drove around to the back of the facility which is not where she was normally unloaded. Resident #13 said she was normally unloaded at the front of the facility. She said Van Driver D was unloading her from the van and was not paying attention and did not click the seat belt to hold her in. Resident #13 said Van Driver D started lowering the van lift and about halfway down to the ground she heard Van Driver D say, uh oh and then she fell off the lift and hit the ground on her head. Resident #13 said after she fell staff had come outside and were debating on if they should send Resident #13 to the hospital. Resident #13 said staff picked her up and put her back in her w/c and took her inside the facility. She said once she was back in the facility that is when the facility decided to send her to the ER. Resident #13 said she went to the local hospital and was life flighted to another hospital. Resident #13 said the facility was blaming the incident on her bag that hangs on the back of her w/c for dialysis. Resident #13 said the dialysis bag had nothing to do with the fall and Van Driver D was just not paying attention to what she was doing. Resident #13 said Van Driver D admitted that it was her fault that Resident #13 had fallen. During an interview by phone on 03/24/24 at 11:56 AM Van Driver D said that on 2/28/24 she had parked the van at the end of 500 hall to unload residents off the van. Van Driver D said it was cold outside that day so she parked the van at the end of 500 hall so residents would be closer to their rooms when she unloaded them. She said Resident #13 was on the lift and was about halfway down about even with the van bumper when all of a sudden, Resident #13 fell off of the lift. Van Driver D said she did not remember if the seat belt was latched or not. She said then she ran inside and got the nurse to come and assess Resident #13. She said Resident #13 was brought back inside the building and then sent to the ER. She said the facility had done education with her prior to the incident on how to properly load and unload a resident. Van Driver D said she had not driven the van since the incident. During an interview and observation on 3/24/2024 at 2:30 pm Van Driver E said he had worked at the facility for about 3 years and was the van driver prior to Van Driver D. Van Driver E said he had taken over transporting residents since the incident on 02/28/2024. Van Driver E demonstrated the process for unloading a resident using the wheelchair mechanical lift. Prior to placing the resident on the lift, the Van Driver E did a safety check of the safety belt by latching and pulling on belt to ensure it was fastened. He then stood on the lift to ensure it was secure. Van Driver E then placed resident on the lift by rolling the resident from the interior of the van onto the lift ramp. Van Driver E secured the wheelchair by locking the wheels, checked the safety belt again to ensure it was secured and fastened, placed the resident's hands on the bars and left all resident belongings or bags in the van until the resident was unloaded. Van Driver E stood behind the wheelchair with hands on the grips as he lowered the resident from the van. Van Driver E said the Maintenance Director had done all of the training with Van Driver D prior to her driving the van. Van Driver E said he rode with Van Driver D for her first week of transporting and did not have any concerns. During an interview on 03/26/24 at 10:25 AM Van Driver D said she had worked at the facility since 1/2024. She said on 2/28/24 she parked at the end of 500 hall to unload Resident #13. Van Driver D said she had two other residents on the van that she unloaded first without incident. She said she went to open the facility door for the first two residents that she had already unloaded and then came back to the van to unload Resident #13. She said the ramp was already down with the seat belt latched. She said she raised the lift back up and went to unbuckle Resident #13 from inside the van. Van Driver D said she rolled Resident #13 back on to the lift with Resident #13 facing the windshield and locked her wheelchair brakes. She said she had already latched the seat belt previously, so she did not latch it again. Van Driver D then said she is not a hundred percent sure she latched the seatbelt because it becomes like muscle memory and said she did not remember seeing if the seatbelt was latched. She said she was standing outside of the van and started lowering the lift. She said when the lift was about halfway down level with the van bumper, Resident #13 and her w/c fell off the back of the lift. Van Driver D said she tried to catch the resident but was not able to. She said she did not move Resident #13; she ran inside to get the nurse. Van Driver D said she stayed with Resident #13 until she was sent out to the hospital. Van Driver D said she had not driven the van since the incident. Van Driver D said she had been given a new job title of hospitality aide and would no longer be driving the van. During an interview and observation on 03/26/24 at 10:42 AM The Maintenance Director said he had worked at the facility since 2013. He said he did not witness the incident with Resident #13 on 02/28/2024. He said he inspected the van after the incident on 02/28/2024 and did not find any issues with the van. He said he inspects the van every Friday. He said the drivers were to inspect the van daily before transporting any residents. The Maintenance Director said prior to placing a resident on the lift, the Van Driver should do a safety check of the safety belt by latching and pulling on belt to ensure it was fastened. The Maintenance Director demonstrated the lift being raised and lowered to demonstrate the safety features of the lift. The Maintenance Director demonstrated that if anything touches the back ramp of the lift the lift will automatically stop moving. The Maintenance Director said he had completed Van Driver D's van training upon hire before transporting any residents and had no concerns. During an interview on 03/26/24 at 11:08 AM the DON said she had been the DON for 6-7 years. She said her expectation is for all residents to arrive timely and safely to appointments. She said she had not been trained on the facility van. She said she expects all van drivers to be trained and follow the policy and procedures when loading/unloading residents. During an interview on 03/26/24 at 11:11 AM the Regional Nurse Consultant said she expects van drivers to follow policy and procedures and protect the residents when transporting. During an interview on 03/26/24 at 11:11 AM the ADO said he expects van drivers to follow policy and procedures and protect the residents when transporting. During an interview on 03/26/24 at 11:11 AM the Administrator said she expects van drivers to follow policy and procedures of loading/unloading residents and protect the residents when transporting. Record review of employee disciplinary report revealed: Van Driver D was placed on investigatory suspension pending an investigation into allegations of resident treatment on 02/28/2024. Record review of witness statement provided by Van Driver D on 02/28/2024 at 3:30 PM revealed: [Resident #13] was in the van, and I had unlocked her straps and seatbelt. I pushed her back onto the ramp, and locked her wheels. Coming halfway down, the seatbelt popped off, and her chair went back. Her wheels were locked. She then fell backward and landed on her side and hit the back of her head. I didn't want to risk moving her, so I ran inside and got a nurse and aides. They checked her and got her up. She didn't have any obvious injuries other than a bump on her head. They brought her inside and sent her to the hospital. Signed by Van Driver D. Record review of witness statement provided by the Maintenance Director undated revealed: February 28, 2024. I [Maintenance Director] did investigate with a wheelchair on the lift in the van it flipping over. I tried using my legs and hands pushing back against it trying to flip the wheelchair to flip over. The wheelchair never flipped over. I tried this using the seatbelt and not using the seatbelt. Both actions produced the same thing of not flipping over. Signed by the Maintenance Director. Record review of a witness statement provided by the DON undated revealed: On Saturday 03/02/2024, I was working as a CNA covering 500 hall. Myself and the ADON, was making rounds and went into [Resident #13's] room to check on her. We spoke to her regarding the incident on the van .I then asked if she remember the van driver locking her wheels and securing the seatbelt behind her, she replied yes, but they must have come undone, because when she started lowering me down, I started rolling back and flipped out of my chair backwards and landed on the ground. Signed by the DON. Record review of vehicle inspection report dated 02/23/2024 revealed: 1. Seat belts clean and in good working condition was marked acceptable. 2. Wheelchair tie-downs inspected and working properly was marked acceptable. Vehicle inspector: Van Driver E/Maintenance Director. Record review of personnel file for Van Driver D revealed, Van Driver D had completed all employee auto training on 01/05/2024. Record review of the facility Employee Auto Training Handbook undated revealed: Wheelchair lifts make it possible to load wheelchairs of all weights in an efficient and safe manner. However, lifts are potentially hazardous equipment. They must be maintained and operated properly. Considerable caution and awareness is needed when operating a lift. Unloading: 4. Staff will stand behind wheelchair and will pull the resident onto the lift, lock brakes, place seatbelt around the rider (if available) and encourage the rider to hold handrails (if available). Staff will then lower the lift to ground until completely on the ground before unloading resident from the lift. Record review of QAPI notes dated 02/28/2024 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS nurse, Activity Director, Assistant Business Office Manager, Human Resources Coordinator, Therapy, Maintenance Director and Medical Records. The interventions and plan for correction included: 1. Self report to HHSC. 2. The facility van was removed from service on 2/28/24. 3. On 2/28/24 & 2/29/24 the Maintenance Director and Administrator tested the lift with a staff member in a wheelchair to ensure that nothing was causing the wheelchair to tip. 4. No resident transport in the facility van until it has been assessed by maintenance staff for proper functioning of all safety devices/equipment. 5. Suspend known perpetrators immediately pending investigation. 6. Take statements from everyone involved or with potential knowledge/involvement. 7. Begin Abuse/Neglect in-service and/or assign course regarding abuse/neglect for all staff who transport or assist with transporting residents in the van. 8. The Maintenance Director and/or designee verified that all resident's wheelchair locks are functioning properly. 9. Inservice staff who transport or assist with transporting resident in the van on the following (with return demonstration): Staff members not inserviced will not transport residents. a. How to safely load and unload resident in the van using the lift. b. Insure when lift safety belt is buckled you hear an audible click. Once clicked, pull the belt as to try and pull it out of the buckle. If no click heard or the belt pulls loose from the buckle, notify the administrator and maintenance director immediately and do not attempt to lift or lower resident. c. When loading or unloading a resident, make sure the vehicle is parked on as flat a surface as possible. d. Properly securing a resident in the van. 10. Inservice all nursing staff to report immediately to the maintenance director if a resident's wheels do not lock once engaged . 11. Maintain a list of staff who have completed training and provided return demonstration regarding transporting a resident in the van. Staff not listed will not transport residents. 12. Complete risk management entry as other in Point Click Care. Record review of sign in sheets for in-service dated 2/28/24 through 3/5/24 indicated that 64 staff members had signed the sign in sheet for the in-service on Abuse & Neglect P&P. Record review of sign in sheets for in-service dated 2/28/24 indicated that 58 staff members had signed the sign in sheet for the in-service on Report immediately to the Maintenance Director any loose, broken, missing brakes on w/c that do not engage. Record review of sign in sheets for in-service dated 2/28/24 indicated that 3 staff members had signed the sign in sheet for the in-service on Securing Residents in Van. Record review of sign in sheets for in-service dated 2/28/24 indicated that 3 staff members had signed the sign in sheet for the in-service on When loading or unloading a resident make sure the vehicle is parked on as flat a surface as possible. Record review of sign in sheets for in-service dated 2/28/24 indicated that 3 staff members had signed the sign in sheet for the in-service on Ensure when the lift safety belt is buckled you hear an audible click. Record review of sign in sheets for in-service dated 2/28/24 indicated that 3 staff members had signed the sign in sheet for the in-service on No Bags, Luggage or other storage containers are to be on w/c during loading and unloading residents. Record Review of Van Driver D re-education on Employee Auto Training Handbook completed dated 2/28/24. Record review of Van Incident Monitoring dated 2/29/24 through 3/22/24 revealed 5 resident wheel chairs each week were checked to ensure brakes are functioning properly, and 5 instances a week of loading/unloading of a resident using the van lift to ensure the lift was used correctly. On 3/25/24 at 9:32 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 2/28/24 and ended on 3/5/24. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to store foods in accordance with professional standards. The facility failed to date opened items placed in the refrigerator and correctly date dry storage items in the kitchen. These failures could place residents who ate the food from the kitchen at risk for food-borne illness. Findings include: During an observation and interview on [DATE] at 9:15 AM the refrigerator contained a plastic container of a thickened white liquid and a large square plastic container with a red lid that had a gelatin type substance inside that was not dated. The dietary manager identified the white liquid as thickened milk. She said that both items were recently made. During an observation and interview on [DATE] at 9:30 AM, the large plastic dry goods storage for sugar and breadcrumbs had a label with an open date of [DATE] and good by date of [DATE]. The dietary manager said that the items were not out of date and that the containers were just filled and that the labels were not changed when the containers were last filled. During an interview on [DATE] at 09:30 AM dietary aide who has been working in the facility for 1 week said that any foods stored after opening or cooking must be labeled with date that is opened and date to be used by. She said that residents are at risk for food poisoning and getting sick if they eat food that is spoiled. During an interview on [DATE] at 09:35 AM with cook who has been working for the facility for 3 months, he said that after an item is placed in a container that can be closed or sealed a label is placed on the item with the open date and a use by date. He said that all items that are placed in the refrigerator and freezer must be dated. He said that residents could become ill and even die if they are given food past expiration date. During an interview on [DATE] at 09:45 AM with the dietary manager, who has been working at the facility for 8 months, she said that all foods that are placed in the refrigerator and freezer and any opened items in dry storage should have a label with the opening date and a use by date. She said that she expects the staff to label and put correct dates on products. She said that staff putting the food away is responsible for making sure that labels are on items. She said that the residents can get sick if expired foods are given to residents. She said that she plans on educating the staff on food storage and labeling and she plans to do monitoring of foods and labels the days that she is in the building. During an interview on [DATE] at 10:00 AM with the administrator, she said that the dietary manager will be conducting inservices with the dietary staff on labeling and storage of foods in the kitchen. She said that the dietary manager will do daily checks of all items being stored and the administrator will do weekly rounds in the kitchen and will check labels of items being stored. She said that she expects the dietary manager to do frequent education with her staff. She said that improperly labeling food after opening puts the resident at risk for food borne illness. Record review of a facility policy titled Food Storage and Supplies dated 2012 indicated, .open packages are stored in closed containers .and dated as to when opened .

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 2 out of 2 meals (the lunch meal on 03/25/24 and breakfast 03/26/24) reviewed for food and nutrition services. The facility failed to ensure residents (Resident # 8 and Resident #150) were served margarine listed on the menu during the lunch meal on 03/25/24 and breakfast 03/26/24. This failure could place residents at risk for unwanted weight loss and decrease satisfaction with meals. Findings included: Review of Resident #8's face sheet, dated 03/26/24, reflected he was an [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis included muscle weakness, difficulty walking and lack of coordination. Review of Resident #8's Admission MDS Assessment, dated 02/15/24, reflected he had a BIMS of 14 indicating he was cognitively intact and required set up service only for meals. Review of Resident #8's Physician Order summary for March 2024 indicated an order for a regular no salt on table diet. Review of Resident #150's face sheet, dated 03/26/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included protein calorie malnutrition (lack of protein intake) and pneumonia (lung infection). Review of Resident #150's Admission MDS Assessment, dated 02/14/24, reflected she had a BIMS of 15 indicating she was cognitively intact and required set up service only for meals. Review of Resident #150's Physician Order summary for March 2024 indicated an order for a regular diet. Review of the facility's menu for the lunch meal on 03/25/24 revealed margarine was listed. Review of the facility's menu for the breakfast meal on 03/26/24 revealed margarine was listed. During an interview on 03/24/24 at 11:04 AM with family and Resident #8, family of Resident #8 said he was admitted to the facility for therapy after surgery on his leg for fracture. Resident #8 said he rarely gets his margarine for a roll, and it will be listed on the sheet of paper (listing all items given to him with meals that comes with the meal). During an observation on 03/25/24 at 12:30 PM, lunch trays for 6 residents on 100 hall did not receive any margarine on the trays and it is listed on all of the tray cards. Record review of a tray card for Resident #8 reflected regular diet margarine is listed on the tray card but was not provided. During an observation and interview on 03/26/24 at 08:01 AM, CNA A was passing out breakfast trays on the 200 hall. CNA A said that the kitchen staff checks the trays for accuracy and puts the condiments on the trays. She said the nursing staff do not add any items before passing them out to the residents. During an observation on 03/26/24 at 08:05 AM breakfast trays for 6 residents on the 100 hall, there was no margarine for the toast and oatmeal on the 6 trays. All 6 tray slips indicated margarine was to be served. During an observation and interview on 03/26/24 at 08:10 AM Resident #150 was eating from her breakfast tray, there was no margarine on the tray. Resident #150 said she did not get margarine today for her toast and oatmeal. She said it is listed on her tray card to be included with her meal. She said that happens a lot, but she hates to complain about it. During an observation and interview on 03/26/24 at 08:15 AM with Dietary Director, a large bowl of margarine packets was sitting by the window in the kitchen. The Dietary Director asked the Cook why the margarine was not on the trays, and he shrugged his shoulders. The Dietary Manager said that the margarine should be added to the trays as they are made in the kitchen and should be verified by the nursing staff when they check the tray cards. The Dietary Director said the condiments such as margarine should be provided as indicated on the tray card because they are a part of the diet orders for the daily menus and provide additional calories. Not getting condiments could keep the residents from enjoying meals. During an interview on 03/26/24 at 11:30 AM the Administrator said the facility started a performance improvement plan regarding the residents not receiving the condiments on the menu. The Administrator provided a Dietary Performance Improvement Activity Plan to begin on 3/25/24 with action items of condiments will be available and provided per resident choice, Goal: Ensure safe and palatable meals and the Dietary Manager and the Administrator are responsible. The Administrator said not getting the condiment could cause the residents not to enjoy their meals. Record review of an undated Facility policy titled Resident Meal Service and Hour of Sleep snack indicated, .1.Upon admission and periodically thereafter, the resident and or family member will be interviewed by the dietary manager or designee to determine individual Food preferences, dislikes and allergies resident preferences will be honored .

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 6 residents (Resident #41) reviewed for comprehensive care plans. The facility failed to care plan Resident #41's refusals to allow staff to perform tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea)) care. The facility failed to care plan Resident #41's desire to perform her own tracheostomy care. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of a facility face sheet dated 3/26/24 for Resident #41 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (a serious condition that causes fluid to build up in your lungs; it results in low oxygen in the blood). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #41 indicated that she had a BIMS score of 12, which indicated that she had a moderate cognitive impairment. Section O indicated that Resident #41 received tracheostomy care. Record review of a Comprehensive Care Plan dated 3/24/24 for Resident #41 did not address that resident was safe to perform own tracheostomy care, that she often refused staff to perform tracheostomy care, or that she was performing it on her own. Review of a physician order report dated 3/24/24 for Resident #41 indicated that she had the following physician orders: Tracheostomy care every day and evening shift; and Tracheostomy care every 6 hours as needed. Record review of Resident #41's electronic medical record indicated there was no safe assessment for her to safely perform her own tracheostomy care. Record review of a physician order dated 2/29/24 for Resident #41 indicated that she had the following order: Augmentin Oral tablet 500-125 mg. Give 1 tablet by mouth two times a day for infection until 3/10/24. Record review of a Skin/Soft-Tissue Infection or Cellulitis Note dated 3/4/24 for Resident #41 indicated that the location of infection was stoma/trach (a hole in the windpipe). During an observation and interview on 3/24/24 at 3:41 pm Resident #41 was observed lying in bed, head of bed elevated, with overbed table in front of her. An opened tracheostomy care kit was on table, and she was cleaning her inner cannula without wearing gloves. Resident #41 said that she always performed her own tracheostomy care. Hand sanitizer was observed on the table next to the tracheostomy care supplies. During an interview on 3/14/24 at 3:50 pm LVN B said that Resident #41 was very particular and would not allow nurses to perform her tracheostomy care. She said that she had educated her multiple times on the risks, but that Resident #41 continued to insist on performing it herself. She said that Resident #41 never wore gloves because she claimed that her hands were sterile. During an interview on 3/25/24 at 3:45 pm LVN C said Resident #41 preferred to perform her own tracheostomy care and normally would not allow the nurses to do it. She said she had educated her multiple times on the risks, but Resident #41 was very adamant that she knew what she was doing. During an interview on 3/25/24 at 4:00 pm Resident #41 said that staff would bring her the kits to perform her own tracheostomy care and that she has had the tracheostomy care for about 8 years. She said, I know what I am doing. She said she was aware of the risks and that staff would tell her all the time about the risk of infection. She said she had not had any issues with infections. During an interview on 3/25/24 at 4:30 pm DON said that the staff were educating Resident #41 often on risks but that she preferred to do her own tracheostomy care despite the risks, and she was very noncompliant. During an interview on 3/26/24 at 8:45 am DON said that Resident #41's physician was aware of her performing her own tracheostomy care. She said that Resident #41 could be at increased risk of infections by performing her own tracheostomy care. During an interview on 3/26/24 at 12:07 pm DON said that if resident care plans were not comprehensive or did not include all needed care, then residents could be at risk of not getting the needed care or interventions and could lead to possible decline. She said going forward, they now have a Performance Improvement Plan in place, and she would be ensuring that care plans were completed appropriately and timely. She said she thought that Resident #41's tracheostomy care refusals and performing her own tracheostomy care had been care planned prior to surveyor entrance, but it must have just gotten missed. During a joint interview on 3/26/24 at 12:20 pm MDS G and MDS H both said they normally take just one day a week, print off a roster and check the names off as they go while doing care plans so they can keep up with who they have done. MDS G said she reviewed admitted s and would set target dates from there. MDS H said they may be able to make a calendar to help them keep up and add residents to the calendar as soon as they come in. MDS H said that floor staff may not know how to care for residents if the care plans were not completed and contain needed information. During an interview on 3/26/24 at 12:30 pm CNA F said that she cared for Resident #41 often. She said Resident #41 was very independent and liked to do her own tracheostomy care. She said she had never watched her do it as she was not a nurse but that she knew she did wash her hands frequently when she was out of bed, and she kept hand sanitizer nearby to use when she was in the bed. Record review of a facility policy titled Comprehensive Care Planning undated read .In situations where a resident's choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan .

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 2 of 12 residents (Residents #41 and #81) reviewed for respiratory care. The facility failed to ensure that Resident #41 was safe to perform her own tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea)) care. The facility failed to ensure Resident #81's nebulizer mask was dated and stored properly between use. These failures could place residents requiring respiratory therapy at risk of hypoxia, infections and not receiving prescribed care and services. Findings include: 1. Record review of a facility face sheet dated 3/26/24 for Resident #41 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (a serious condition that causes fluid to build up in your lungs; it results in low oxygen in the blood). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #41 indicated that she had a BIMS score of 12, which indicated that she had a moderate cognitive impairment. Section O indicated that Resident #41 received tracheostomy care. Record review of a Comprehensive Care Plan dated 3/24/24 for Resident #41 did not address that resident was safe to perform own tracheostomy care, that she often refused staff to perform tracheostomy care, or that she was performing it on her own. Review of a physician order report dated 3/24/24 for Resident #41 indicated that she had the following physician orders: Tracheostomy care every day and evening shift; and Tracheostomy care every 6 hours as needed. Record review of Resident #41 electronic medical record indicated there was no safe assessment for her to safely perform her own tracheostomy care. Record review of a physician order dated 2/29/24 for Resident #41 indicated that she had the following order: Augmentin Oral tablet 500-125 mg. Give 1 tablet by mouth two times a day for infection until 3/10/24. Record review of a Skin/Soft-Tissue Infection or Cellulitis Note dated 3/4/24 for Resident #41 indicated that the location of infection was stoma/trach (a hole in the windpipe). During an observation and interview on 3/24/24 at 3:41 pm Resident #41 was observed lying in bed, head of bed elevated, with overbed table in front of her. An opened tracheostomy care kit was on table, and she was cleaning her inner cannula without wearing gloves. Resident #41 said that she always performed her own tracheostomy care. Hand sanitizer observed on table next to tracheostomy care supplies, Resident #41 was not observed using hand sanitizer, she simply said that her hands were already clean. During an interview on 3/14/24 at 3:50 pm LVN B said that Resident #41 was very particular and would not allow nurses to perform her tracheostomy care. She said that she had educated her multiple times on the risks of not wearing gloves, but that Resident #41 continued to insist on performing it herself. She said that Resident #41 never wore gloves because she claimed that her hands were sterile. During an interview on 3/25/24 at 3:45 pm LVN C said Resident #41 preferred to perform her own tracheostomy care and normally would not allow the nurses to do it. She said she would document refused on the treatment record when she cared for Resident #41, and she would not allow her to perform it. She said she had educated her multiple times on the risks, but Resident #41 was very adamant that she knew what she was doing. During an interview on 3/25/24 at 4:00 pm Resident #41 said that staff bring her the kits to perform her own tracheostomy care and that she has had the tracheostomy care for about 8 years. She said, I know what I am doing. She said she was aware of the risks and that staff would tell her all the time about the risk of infection. She said she had not had any issues with infections. During an interview on 3/25/24 at 4:30 pm DON said that the staff educated Resident #41 often on risks but that she preferred to do her own tracheostomy care despite the risks, and she was very noncompliant. DON said she would educate Resident #41 again on the risks and if she wished to continue performing her own care she would have her sign a Negotiated Risk Assessment form. During an interview on 3/26/24 at 8:45 am DON said that Resident #41's physician was aware of her performing her own tracheostomy care. She said that Resident #41 could be at increased risk of infections by performing her own tracheostomy care. Record review of a Negotiated Risk Agreement dated 3/25/24 and signed by Resident #41 and DON indicated that resident had been informed of risks of providing own trach care such as respiratory failure, risk of infection, choking and death. Resident signed form acknowledging that she had been informed of the risks and that she would continue to perform own trach care. Record review of an attestation dated 3/20/24 indicated that Resident #41 desire to continue performing her own tracheostomy care despite being educated on the risks was discussed in a QAPI meeting with physician on 3/20/24. 2. Record review of facility face sheet dated 3/25/2024 indicated Resident # 81 was [AGE] years old and was admitted to the facility on [DATE] with diagnosis of dementia. Record review of admission MDS assessment dated [DATE] indicated Resident # 81 had a BIMS of 10 indicating moderately impaired cognition. Record review of a comprehensive care plan dated 10/02/2023 indicated Resident # 81 had shortness of breath and to monitor and treat as needed. Record review of a physician order dated 10/02/2023 revealed Resident #81 had an order for budesonide inhalation suspension one inhalation two times a day for shortness of breath. Record review of consolidated physician orders dated 3/25/2024 revealed no order for changing Resident #81's nebulizer mask. During an observation and interview on 03/24/24 at 10:32 AM Resident # 81 had a nebulizer mask laying on her bedside table that was not bagged and the tubing was not dated. She said the nurse changed the nebulizer last week some time and she used her nebulizer at least two times a day. She said there had not been a bag for the mask to go into that she recalled, and it just lays on her table. During an observation on 3/26/2024 at 9:00 AM Resident #81 had a nebulizer mask laying on her bedside table that was not bagged for storage. During an interview on 03/26/24 at 09:30 AM LVN C said she had worked at the facility for one year. She said residents that received nebulizer treatments should have an order for the medicine and for a weekly change in the mask. She said when the nebulizer mask was changed it should be signed off on the treatment record and then dated and placed in a plastic bag. She said that she was not aware that Resident #81 did not have an order to change her nebulizer mask weekly and that it was not properly stored. She stated Resident #81 did have a plastic bag for her mask, but it was in her bedside table drawer. She stated if nebulizer masks were not changed and stored properly it could cause infections. During an interview on 03/26/24 at 9:46 AM the DON stated that all nebulizer orders were the responsibility of the nurse entering the order and the order should include a weekly change of the mask. She stated the nebulizer mask should be dated when it was changed and then placed in a plastic bag after use. She stated she and the ADON made rounds daily to check for oxygen and nebulizers and they must have missed Resident #81's not being dated and bagged. She stated she expected the staff to follow the facility policy for nebulizers to prevent cross contamination. During an interview on 3/26/24 at 11:32 am Administrator said that residents performing their own tracheostomy care could be at risk of possible obstruction and causing problems with the tracheostomy leading to breathing problems. She said going forward they would provide more education to nurses and residents on the increased risks. She said they might possibly have staff members observe her while doing tracheostomy care if Resident #41 would allow it. She said she would have staff keep the physician notified of any changes or incidents with Resident #41's tracheostomy care. She said that nebulizer masks not being dated and bagged could also lead to increased risks of infections. She said she would educate staff on dating and bagging masks and ensure that it was done going forward. Record review of a facility procedure titled Tracheostomy Care Procedure dated 2003, revised on 10/19/09 read .Tracheostomy care is a procedure designed to maintain a patient airway and a sterile/clean area in and around a patient's tracheostomy. This procedure is performed using aseptic (clean) technique at least every 12 hours and as needed .the procedure requires 2 people . Record review of a facility policy titled Breathing Therapy Devices dated 2/13/2007 indicated, .7.store in a clean plastic bag for future use . 46436

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #23 and #24) and 1 of 5 staff (MA H) reviewed for infection control. MA H failed to perform hand hygiene during medication administration for Residents #23 and #24 on 3/25/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings include: 1.Record review of an Admission Record for Resident #23 dated 3/25/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of dementia (a group of thinking and social symptoms that interfere with daily living), Type 2 diabetes, systolic heart failure (a heart failure that occurs in the bottom chambers of the heart) and BPH (enlarged prostate). Record review of a care plan for Resident #23 revised on 2/12/2024 indicated he had a current pressure ulcer with potential for further pressure that included interventions to administer medications as ordered. Record review of an active physician order summary report dated 3/26/2024 for Resident #23 indicated he had an order that the facility may crush medications or open capsules as needed unless contraindicated (no reason to), Record review of an Admission MDS assessment for Resident #23 dated 12/31/2023 indicated he had moderate impairment in thinking with a BIMS score of 11. During a medication pass observation on 3/25/2024 at 8:05 Am, MA H did not sanitize or wash her hands before she took Resident #23's blood pressure. She unlocked the medication cart and took out his medications and placed them in a small plastic cup. She locked the medication cart and reentered the room of Resident #23 and administered the medications to him. She exited the room and did not wash or sanitize her hands. 2. Record review of an Admission Record for Resident #24 dated 3/26/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of type 2 diabetes, lymphedema (swelling caused by a blockage) and major depressive disorder (persistent feeling of sadness or loss of interest). Record review of an Annual MDS Assessment for Resident #24 dated 12/29/2023 indicated she had moderate impairment in thinking with a BIMS score of 11. Record review of a care plan for Resident #24 revised on 12/5/2021 indicated she was on diuretic (fluid medication) therapy that included interventions to administer medications as ordered. During a medication pass observation on 3/25/2024 at 8:17 AM, MA H did not wash or sanitize her hands before unlocking the medication cart to get medications for Resident #24. She placed the medications for Resident #24 into a small plastic cup and entered the room to administer the medications to Resident #24. While in Resident #24's room, Resident #24 questioned MA about the little pill and wanted to know why she did not get it. MA H told Resident #24 that she would check, and she left the room and reentered the medication cart without washing or sanitizing her hands and took out a furosemide 20 mg tablet (fluid pill) that should have been given at the time of the other medications. MA H administered the furosemide tablet to Resident #24. After MA H exited the room, she sanitized her hands. Record review of an active physician order summary report for Resident #24 dated 3/26/2024 indicated an order for furosemide 20 mg give one tablet one time a day by mouth for edema with a start date of 8/3/2021. During an interview on 3/25/2024 at 8:42 AM, MA H said she had been employed at the facility since November 2023 and worked the day shift from 6 am to 2 pm and always worked the same hall. She said another medication aide in the facility trained her and did a check off with her on medication administration. She said during the observation of medication pass, she should have sanitized her hands before she opened the cart, and before and after administering medications to each resident. She said sanitizer was in her cart, but she was nervous during the observation and did not sanitize her hands. She said residents could be at risk for transfer of germs and possible diseases. Record review of a Medication Aide Proficiency Audit dated 11/17/2023 for MA H indicated she demonstrated satisfactory proficiency with infection control and proper handwashing by the DON. During an interview on 3/26/2024 at 9:15 AM, the ADON said there were two ADON's and the DON at the facility that were responsible for conducting skill check offs with staff. She said the check offs were conducted on hire and annually. She said hand hygiene during medication administration should be conducted before, between, after each resident and any time hands were visibly soiled. She said residents could be at risk for infections with staff spreading germs by not washing or sanitizing their hands. During an interview on 3/26/2024 at 9:25 AM, the DON said there were two ADON's and herself that were responsible for conducting skill check offs with staff on hand hygiene. She said they tried to conduct them at least every quarter with each staff. She said hand hygiene during medication administration should be done before and after and anytime hands were visibly soiled. She said going forward, she would continue to educate with in-service training to the staff. She said residents could be at risk for contamination with viruses and infection if staff did not perform hand hygiene during medication administration. During an interview on 3/26/2024 at 9:30 AM, the Administrator said the ADON's, and the DON were responsible for providing education with in-service training and return demonstration to all staff on hand hygiene. She said hand hygiene during medication administration should be done before, after, and in between residents and any time going from dirty to clean. She said going forward they would continue to monitor for compliance and with return demonstration on hand hygiene. She said residents could be at risk for infections. Record review of a facility policy titled Fundamentals of Infection Control Precautions undated indicated, .A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. 1. Hand Hygiene continues to be the primary means of preventing the transmission of infection, when coming on duty; before and after direct resident contact; upon and after coming in contact with a resident's intact skin; after completing duty .

Based on observation, interview, and record review the facility failed to ensure the residents environment remained free from accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #4, #8, and #9) reviewed for accidents, hazards, and supervision. 1.The facility failed to adequately supervise Resident #4 when being transferred. Resident #4 sustained a fracture of the proximal tibia (broken bone below the knee) when the Hoyer lift tipped over while being transferred with a Hoyer lift device (a mobility device with a U-shaped base and an overhead horizontal bar with hooks on top. A sling suspended by loops or metal clips attached to the overhead bar with hooks. The lift is used to lift and transport people who cannot safely walk or put weight on either leg) by CNA A on 09/07/23. 2. The facility failed to ensure that on 9/26/23 at 10:26 am CNA B and CNA C opened the legs to stabilize base of Hoyer lift during transfer of Resident #9 from geri-chair to bed. 3. The facility failed to ensure that on 9/26/23 at 11:36 am CNA D and CNA E opened the legs to stabilize base of Hoyer lift during transfer of Resident #8 from shower bed to geri-chair. An Immediate Jeopardy (IJ) was identified on 9/26/23 at 2:50 pm. The IJ template was provided to the facility on [DATE] at 3:01 pm. While the IJ was removed on 9/27/23, the facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy and scope of isolated due to the facility's need evaluate and monitor the effectiveness of corrective systems. These failures placed residents at risk of falls, fractures, and death. Findings include: 1. Record review of a face sheet dated 9/26/23 for Resident #4 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: nondisplaced fracture of right tibial tuberosity (fractures that occur in the bony prominence on the front of the tibia (shin bone) near the knee), Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system). Record review of Resident #4's Annual Comprehensive MDS, dated [DATE], indicated that he had a BIMS score of 15, which indicated no cognitive impairment. The MDS further indicated the resident's functional status was a 3 for transfers which indicated he required extensive assistance and a 3 for support in transfers which indicated he required two or more persons assist. Record review of a care plan for Resident #4 with revision date of 10/9/20 read .requires total assist X 2 staff with use of Hoyer lift . Record review of a facility in-service sheet dated 8/17/23, titled read CNAs - get a gait belt and keep one on you. You must use a gait belt for transfers you assist with other than Hoyer lifts. Hoyer lift transfer requires 2 people indicated that CNA A had signed the in-service sheet. Record review of a nurses note for Resident #4 dated 9/7/23 at 10:45 am read Summoned to shower room by ADON [name] stating that resident was on the floor. This nurse entered shower room and observed resident lying on the floor in the middle of the shower room on his back. Resident assessed for injuries no apparent injuries noted. Resident c/o slight pain to right hip 3-10 and pain 7-10 to right knee. Resident refused to go to ER stating that he did not think he needed to go. Resident requested to be put back into his bed. This nurse 2 other nurses and shower tech assisted resident off the floor and back into his bed via mechanical lift. Report to [name], PA for Dr. [name] residents fall and refusal to go to ER. [Name] gave orders for mobile X-ray, 2 view of right knee and 2 view of right hip. [Name] imaging called, and orders placed for x-rays. RP and DON aware of incident and orders received. Signed by LVN G. Record review of a witness statement dated 9/7/23 and signed by CNA A, read I, [name], CNA tried to transfer [name (Resident #4)] to his chair from the shower bed with the Hoyer lift. The Hoyer lift leg hit the shower bed leg and caused it to flip. I hurry hold the lift pad and put [name (Resident #4)] down on the floor to prevent from get hurt. I asked him if he hit his head, he said no. The accident was report. Record review of a nurses note for Resident #4 dated 9/7/23 at 2:10 pm read received x-ray results and impressions indicate possible Fx [fracture] to the left femur. Right knee is negative for any acute fractures this nurse reported findings to [name] PA for Dr. [name] and received new orders for 2 view x-ray of the left hip and femur. Resident continues to deny pain to bilateral hips and reports pain 5/10 to right knee. Signed by LVN G. Record review of a nurses note for Resident #4 dated 9/7/23 at 9:08 pm read Impression to left hip negative for Fx, [family member] and [name] PA notified of results signed by LVN H. Record review of a nurses note for Resident #4 dated 9/8/23 at 7:30 pm read Resident's RP [name] in facility, stated resident continued to have pain to RLE (right lower extremity). Noted slight swelling to leg, no redness or warmth noted. No bruising noted. Per RP request, resident to be sent to ER for eval and tx on 9/9/23 at 11 am. Refused transportation at this time, stated not this late. Transportation set up. Signed by LVN J. Record review of a nurses note for Resident #4 dated 9/9/23 at 11:00 am indicated that resident was transferred to ER at that time for MRI related to recent fall. Record review of hospital records for Resident #4 indicated that resident was admitted to the hospital on 9/9/23 at 2:46 pm with diagnosis of Impacted Fracture of proximal right tibia (A break in the shinbone just below the knee). Hospital course read .Patient was admitted with right knee pain. X-ray of the leg did not show any acute fractures although osteopenia was seen. He continued to have significant knee pain and MRI was done which showed impacted fracture of the proximal tibia which appears late acute/subacute. Orthopedics was consulted and did not recommend any acute surgical interventions. Non weight bearing, no range of motion and knee immobilizer was recommended for the next 4 to 6 weeks . Record review of a nurses note for Resident #4 dated 9/13/23 at 5:20 pm indicated that resident returned to facility at this time via ambulance transfer. 2. Record review of a face sheet dated 9/26/23 for Resident # 9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: seizures (sudden, uncontrolled movements), hypokalemia (low potassium levels in the blood), diabetes (uncontrolled blood sugars), and hypertension (high blood pressure). Record review of Resident #9's Comprehensive MDS dated [DATE] indicated that she was unable to complete the interview for a BIMS score, and she was severely cognitively impaired. The MDS further indicated the resident's functional status was a 3 for transfers which indicated she required extensive assistance and a 3 for support in transfers which indicated she required two or more persons assist. Record review of a care plan for Resident #9 with date of 10/26/22 read .mechanical lift with staff X 2 to assist with transfers . 3. Record review of a face sheet dated 9/26/23 for Resident #8 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: epilepsy (seizures), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and bradycardia (low heart rate). Record review of Resident #8's Comprehensive MDS dated [DATE] indicated that she was unable to complete the interview for a BIMS score, and she was severely cognitively impaired. The MDS further indicated the resident's functional status was a 3 for transfers which indicated she required extensive assistance and a 3 for support in transfers which indicated she required two or more persons assist. Record review of a care plan for Resident #8 with revision date of 9/8/23 read .requires X 2 staff participation with transfers via mechanical lift . During an observation on 9/26/23 at 10:26 am, Resident #9 was observed being transferred from Geri-chair to bed by CNA B and CNA C. CNA B pushed the lift under the resident's Geri chair and both CNAs placed the sling on the red straps in the lift. Resident was lifted out of the chair and rolled over to the bed with the lift legs closed. The lift legs were rolled under the bed and the resident was lowered to the bed. During a joint observation and interview on 9/26/23 at 11:10 am, the Administrator and DON both said that Resident #4 was not actually in the shower when he fell , but in the common area of the room where transfers occurred. Observation of the shower room showed that there were multiple showers off one common open room for residents to transfer from shower beds or shower chairs to their regular chairs or beds. DON said that resident was found on floor in this common room after the fall while being transferred from the shower bed to his chair. During an observation on 9/26/23 at 11:36 am, Resident#8 was observed being transferred in the shower room from shower bed to Geri chair by CNA D and CNA E. CNA D moved the lift under the shower bed, the sling was attached at the green strap. Resident was lifted off the bed and CNA D pulled the lift back with resident in the air. Resident was pushed across the room with the lift. CNA D was in the process of pushing the lift under the Geri chair when LVN F opened the door to ask the CNA a question and said, make sure the legs are open. CNA D then opened the legs on the lift to the widest position. The resident was then lowered into the Geri chair. During an observation and interview on 9/26/23 at 1:20 pm, Resident #4 was observed up in a mechanical wheelchair with a Hoyer lift sling underneath him. Knee immobilizer was in place on right knee, with obvious swelling noted. He said that on the day that he fell , he was being transferred from the shower bed to his wheelchair and something went wrong with the leg on the lift, he was unsure what occurred, but the lift tilted over, and the bars were on his stomach and his leg/knee. He said that he believed that was how the fracture occurred. He said that the bars were very heavy and uncomfortable until they got them off him and got him up. He said he was immediately put back to bed with a lift and there were several staff members using the lift at the time they put him to bed after the fall. He said that the nurses looked over him well and tried to get him to go to the ER, but he did not think he needed to go at that time. He said he continued hurting despite pain medications and he did go to the ER a couple of days later. He said that CNA A had been caring for him for years and had always done the transfers by herself. He said that he did not know to tell her to get another staff member to transfer him. He said that he had an appointment tomorrow with an orthopedic doctor. He said that he would never allow any staff to transfer him without 2 people anymore because he was too nervous and afraid that something else might happen. During an interview with Resident #4's family member on 9/25/23 at 3:45 pm, she said that she was notified of the fall from the Hoyer lift on the day it occurred. She said that she could not remember what time she was notified, but that she had no issues with the way the facility handled it. She said that he seemed fine after the fall, but the next day started complaining of knee pain. She said that she did not want him sent out that day because it was too late but had him sent to theER on Saturday 9/9/23. She said that the ER went back and forth over whether his leg was broken, but he ended up being admitted for a UTI. After admission, she said that they did tell her it was broken. A knee immobilizer was placed, and he would see an orthopedic doctor in the next couple of days. She said that it was her understanding that the employee was suspended pending investigation due to the accident and that she understood that the employee no longer worked here. She said that Resident #4 had multiple sclerosis and had been there about 7 years. During an interview on 9/26/23 at 9:20 am, the Administrator said that CNA A had been suspended and terminated after the incident with Resident #4 and was no longer employed by the facility. She said that CNA A and all other nursing staff had been in-serviced regarding using 2 people for Hoyer lift transfers immediately after the fall. During an attempted telephone interview on 9/26/23 at 10:36 am with CNA A, phone went to message that said not accepting calls at this time and there was no option to leave voicemail. During an interview on 9/26/23 at 10:38 am, CNA C said that she had been in-serviced on mechanical lift transfers but was not sure when. She said she got distracted by the other resident in the room yelling out cuss words while they were transferring Resident #9 and was just nervous and forgot to open the legs of the lift. She said the purpose of opening the legs on the lift was to allow more room to put the resident in the chair or bed. She said there must always be 2 people in the room to do a transfer with the lift. She said that she had been working as a CNA at the facility for about 3 years. During an interview on 9/26/23 at 10:40 am, CNA B said that she had been in serviced about doing transfers with a lift about a month ago. She said she was always supposed to have two people. She said she forgot to open the legs on the lift because the other resident in the room had said a cuss word that had distracted her while they were transferring Resident #9. She said she knew the legs were supposed to be open to help balance the lift. During an interview on 9/26/23 at 10:58 am, CNA K said that she was in serviced on Hoyer lifts upon hire, and she was hired 1 1/2 years ago. She said there was always supposed to be 2 people for all Hoyer lift transfers. During an interview on 9/26/23 at 11:05 am, the Administrator said that she did not have another telephone number for CNA A. During an interview on 9/26/23 at 11:38 am, CNA E said she was in serviced about a month ago. She said she normally opened the legs of the lift and does not know why CNA D didn't open the legs. She said the purpose of opening the legs was for easier access to get the legs around the Geri chair. During an interview on 9/26/23 at 11:42 am, CNA D said she had worked at the facility for 1 year. She said she was in serviced on Hoyer lifts about a week ago. She said they were always supposed to have 2 people in the room for a Hoyer lift transfer. She said she did not open the legs on the lift all the way because the way things were arranged in the shower room, she couldn't maneuver the lift with the legs open. She said when she got the resident over the Geri chair that was when she opened the legs on the lift to fit around the Geri chair properly. During an interview on 9/26/23 at 1:05 pm, LVN F said when she walked into the shower room, from where she was standing it did not look like the legs to the lift were open. She said that was why she told CNA D to make sure the legs of the lift were open. She said they had just received an in-service about a week ago regarding Hoyer lifts. During an interview on 9/27/23 at 3:30 pm, the DON said that the legs of the Hoyer lift should be opened to provide stability to the lift to prevent it from tipping over. She said that the CNAs should have opened the legs on the base of the lift while moving resident. She said that she would be in-servicing staff and expected her staff to always use at least 2 people for Hoyer transfers and to have the legs open for stability. She said that improper Hoyer transfers could put residents at risk for injury, falls, and fractures. She said she had in-serviced staff after the fall with Resident #4, and she was ultimately responsible for training CNAs on proper transfers. She said that CNAs were supposed to check the Kardex for proper methods to transfer residents and she would be doing more in-services with them. Record review of a facility policy titled Hydraulic Lift, undated read .8. Prepare the lift by setting the adjustable base to its widest position . This was determined to be an Immediate Jeopardy (IJ) on 9/26/23 at 2:50 pm. The Administrator and DON were notified. The Administrator was provided with the IJ template at 3:01 pm. The following Plan of Removal submitted by the facility was accepted on 9/27/23 at 8:11 am and included the following: Interventions: * Suspend and terminate CNA A, 9-7-23. * Disciplinary action given for CNA B,C,D,E 9-26-23 by Administrator/HR * 1on1 Hoyer transfer training with return demonstration given to CNA B,C,D,E by DON/ADON/Therapy on 9-26-23 3:15pm * MD notified of IJ 9-26-23 at 3:15pm * Ad hoc QAPI held with Medical Director 9-26-23 4:30pm * All residents were assessed and evaluated for transfer assistance by DON/ADON/MDS/Therapy 9-26-23 4pm * All resident care plans reviewed for accuracy of transfer assistance by MDS 9-26-23 4pm. * All nursing staff checked off on mechanical lift transfers by DON/ADON/Therapy 9-26-23 6:05pm Any staff member not present or in-serviced will not be allowed to assume their duties in providing Hoyer transfer until in-serviced. The following in-services were initiated by Admin/DON on .9/26/23 at 3:15pm. Any direct care staff not present or in-serviced will not be allowed to assume their duties until in-serviced. * Hoyer transfer x 2 staff, prepare lift by setting base to widest position to transfer by DON/ADON/Therapy/MDS 9-26-23 4pm, any staff member not present or in-serviced will not be allowed to assume their duties in providing Hoyer transfer until in-serviced. * How to use the Kardex in PCC to determine the transfer status of a resident 9-26-23 4pm By DON/MDS/ADON/Designee * Following the care plan interventions including how much staff and the proper equipment required for transfers by DON/MDS/ADON/Designee 9-26-23 4pm * If unable to provide the required staff or equipment to perform a transfer, do not perform until staff are available by DON/ADON/MDS/Designee 9-26-23 4pm * If the required number of staff or equipment is not listed for transfers, contact the Charge Nurse, ADON, and or DON immediately by DON/ADON/MDS/designee 9-26-23 4pm Observations, interviews, and record reviews were conducted on 9/27/23 from 2:00 pm to 4:20 pm and included (Administrator, DON, ADON, 3 LVN's, 3 MA's, and 8 CNA's) to ensure these interventions had been completed. Record review of an employee disciplinary report dated 9/15/23 indicated that CNA A was terminated on 9/15/23. Record review of 4 employee disciplinary action request forms dated 9/26/23 indicated that CNAs B, C, D, and E were disciplined with written counseling on 9/26/23 for failure to follow hydraulic lift policy and procedure. Record review of an in-service training sheet with check off sheets indicated that CNAs B, C, D, and E were trained on Hydraulic Lift policy and procedure and were checked off on 9/26/23. Record review of the ad hoc QAPI form indicated that MD was notified of IJ on 9/26/23 at 3:15 pm. Record review of a sign in sheet indicated that ad hoc QAPI was held with Medical Director on 9/26/23 at 4:30 pm. Record review of the attestation form dated 9/26/23 indicated that all residents were assessed and evaluated for transfer assistance by DON/ADON/MDS/Therapy on 9/26/23 at 4:00 pm. Record review of the attestation form dated 9/26/23 indicated that all resident care plans had been reviewed for accuracy of transfer assistance by MDS on 9/26/23 at 4:00 pm. Record review of the skills check off sheets indicated that 60 staff members had been checked off with return demonstration on mechanical lift transfers on 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled Hydraulic Lift policy and procedure x 2 staff; prepare lift base to widest position indicated that 49 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled Kardex training for CNAs. Instructed how to access the Kardex through POC Kiosk for every resident. Kardex has to be accessed for every resident to determine the requirements of staff when performing care including transfers, bed mobility, dressing, toileting, bathing, eating. The Kardex also provides information on the method the resident requires for transfers indicated that 45 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled Accessing CP, CP information pulls the Kardex. Kardex training for CNAs. Instructed how to access Kardex for each resident. Kardex has to be assessed for every resident to determine the requirement for staff when performing care including transfers, bed mobility, dressing, toileting, bathing, and eating The Kardex also provides information on the method the resident requires for transfers indicated that 14 CNAs had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled if unable to provide the required staff or equipment to perform tasks/transfer, do not perform until staff x 2 are available. DO NOT RUSH indicated that 45 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled if the required number of staff or equipment is not listed for transfers, contact charge nurse, ADON, or DON immediately indicated that 46 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Nursing staff were able to appropriately indicate they would only transfer residents using a Hoyer lift if there were at least 2 persons to assist and would only transfer residents with the base open to its widest position. Nursing staff were able to identify resident's care plans, the Kardex system and how to find required level of resident care. CNAs and MAs were able to demonstrate the use of the Kiosk system to find resident care needs. The following staff from day and evening shift were able to verbalize and demonstrate understanding of all in-services given: MA S on 9/27/23 at 2:00 pm CNA O on 9/27/23 at 2:00 pm CNA N on 9/27/23 at 2:05 pm CNA K on 9/27/23 at 2:15 pm LVN J on 9/27/23 at 2:20 pm ADON on 9/27/23 at 2:22 pm MA L on 9/27/23 at 2:25 pm MA M on 9/27/23 at 2:30 pm LVN H on 9/27/23 at 2:30 pm CNA P on 9/27/23 at 2:40 pm CNA Q on 9/27/23 at 2:45 pm CNA U on 9/27/23 at 3:10 pm CNA R on 9/27/23 at 3:15 pm CNA T on 9/27/23 at 3:20 pm The Administrator was informed that the Immediate Jeopardy was removed on 9/27/23 at 4:20 pm. The facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy and scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record reviews, the facility failed to ensure a MDS assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 3 of 7 (Resident #5, Resident #6, and Resident #7) reviewed for MDS information. The facility failed to encode, complete, and submit a discharge MDS for Resident #5 and Resident #6. The facility failed to encode, complete, and submit a death in facility MDS for Resident #7. This deficient practice could place residents at risk of not having records completed and submitted to the CMS system in a timely manner as required. Findings included: 1.Record review of Resident #5's face sheet undated revealed an [AGE] year-old male that admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #5's admission MDS dated [DATE], section Q0300 of the MDS revealed: 1. Expects to be discharged to the community. Record review of Resident #5's MDS assessment completion list did not reveal a Discharge MDS had been completed. 2. Record review of Resident #6's face sheet undated revealed a [AGE] year-old male that admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #6's admission MDS dated [DATE], section Q0300 of the MDS revealed: 1. Expects to be discharged to the community. Record review of Resident #5's MDS assessment completion list did not reveal a Discharge MDS had been completed. 3. Record review of Resident #7's face sheet undated revealed a [AGE] year-old male that admitted to the facility on [DATE] and expired in facility on [DATE]. Record review of Resident #7's significant change MDS dated [DATE], section Q0400 of the MDS revealed: A. Is active discharge planning already occurring for the resident to return to the community? Coded: No. Record review of Resident #7's MDS assessment completion list did not reveal a Death in Facility MDS had been completed. During an interview on [DATE] at 9:04 AM with the MDS LVN, she said she had a scheduler built into the electronic health record. She did not know why Resident #5 and Resident #6 did not have a Discharge MDS or why Resident #7 did not have a Death in Facility MDS. The MDS LVN said that DON did not routinely manage her to ensure that resident MDS's were due or needed to be completed and submitted. She said she did MDS assessments per facility policy. She said there was also a list of opened assessments in the electronic health record. She said they had a corporate consultant that audits MDS completions. During an interview on [DATE] at 9:10 AM with the MDS RN, she said there was a built-in schedule that pops up in the electronic health record when MDS assessments were due. She said both the MDS LVN and MDS RN opened the discharge assessments. She said they both did the discharges together. The MDS RN said she did not know why those assessments were missed without looking. She said they completed assessments per their facility policy. She said discharge assessments should have been completed within 14 days of the event per the facility policy. During an interview on [DATE] at 9:30 AM with the DON, she said that she only signed MDS's if the MDS RN was out of the building. She said that she did not manage the MDS nurse to know if she had missed any resident's MDS's. She said she had to refer to the facility policy to know what MDS's should be completed and in what time frame they should be completed in. She said a death in facility assessment should be done within 14 days of the event date. She said she was not sure what the discharge assessment was used for and does not want to assume. During an interview on [DATE] at 9:45 AM with the Administrator, she said the purpose of the discharge MDS was to close out the resident's record. She said she would refer to the facility policy and it stated a death in facility should be completed within 14 days of the event. She said the policy does not address a discharge from facility assessment. She said there was a scheduler in the computer that the MDS nurses go by and there was a companywide MDS consultant that oversees and audits the MDS that were completed. She said most things in the electronic health record will turn red if not completed timely. The Administrator said she does not know why the MDS were not completed timely. Record review of the undated facility policy labeled Creative Solutions P&P MDS Transmission Reference Chapter 5 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual undated revealed: Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date. Record review of the Resident Assessment Instrument Manual accessed on [DATE] at LONG TERM CARE FACILITY (cms.gov) revealed a Discharge Tracking Assessment was to be completed within 7 days of discharge.

Based on interview and record review, the facility failed to ensure the physician was consulted immediately for changes in condition when a need to alter treatment was indicated for 1 of 4 residents reviewed for physician notification. (Resident #1) LVN A and LVN C did not immediately notify the physician for Resident #1 when she had new onset of vomiting on [DATE]. Resident #1 was transferred to the hospital emergency room where she was diagnosed with [REDACTED].) [MEDICAL CONDITION] (an overwhelming immune response to a bacterial infection. In severe cases, one or more organs fail. In the worst cases, blood pressure drops, and the heart weakens, leading to septic shock.) Resident #1 died on [DATE]. This was determined to be past non-compliance that existed from [DATE] and was corrected on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who experienced a change of condition at risk of increased injury, delayed care, and death. Findings included: Physician orders [REDACTED].#1 was an [AGE] year-old female, admitted [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was at risk for aspiration and orders on [DATE] included aspiration precautions to keep the head of bed elevated 30 to 45 degrees. The most recent MDS dated [DATE] indicated Resident #3 had severe cognitive impairment, minimal difficulty hearing, clear speech, was usually understood, and sometimes understood others. She required extensive assistance of two staff with transfers, bed mobility, dressing, toileting and personal hygiene. Dysphagia was listed under additional active [DIAGNOSES REDACTED]. A care plan initiated [DATE] and revised [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. Interventions included to monitor/document/ notify physician for changes in lung sounds on auscultation i.e., crackles. Monitor/document/ notify physician for heartburn, nausea and vomiting or other signs of [MEDICAL CONDITION]. The care plan further indicated Resident #1's [DIAGNOSES REDACTED]. The care plan indicated Resident #1 was at risk for nutritional deficit due to [MEDICAL CONDITION] and therapeutic diet. Interventions included: Monitor/document/report to MD PRN (as needed) for signs and symptoms of dysphagia- pocketing, choking, coughing, drooling, holding food in mouth. The provider investigation report dated [DATE] indicated on [DATE] at 5:39 p.m. a self-report of neglect was made to the state agency for Resident #1. On [DATE] around 4:00 p.m. CNA B alleged LVN A observed Resident #1 vomiting multiple times during the 10:00 p.m. to 6:00 a.m. shift on [DATE] and [DATE]. The report indicated LVN A did not notify Resident #1's physician of her change in condition, repeated episodes of vomiting, nor had LVN A documented an assessment of Resident #1's change in condition in the clinical record. The investigation further indicated LVN C did not document Resident #1's episode of coughing up and vomiting phlegm and an orange liquid on [DATE] between 2:00 p.m. and 10:00 p.m. and LVN C did not notify physician of Resident #1's change in condition. A TAR dated (MONTH) 2019 indicated Resident #1 was on aspiration precautions-head of bed elevated 30 to 45 degrees each shift for prevention. Nursing initialed from [DATE] through [DATE] on days, evening and nights as performed. A SBAR (situation, background, assessment, and recommendation) communication record dated [DATE] indicated Resident #1 had abdominal/ GI (gastrointestinal) changes, GI bleed, described as coffee ground vomit onset [DATE], with primary [DIAGNOSES REDACTED]. The nurse practitioner was notified on [DATE] at 9:20 a.m. and orders were received to send Resident #1 to the emergency department for evaluation and treatment. Her vital signs indicated a blood pressure of ,[DATE], temperature of 97.9, pulse of 89, and respiratory rate of 20. Her oxygen saturation was 95% on room air. A transfer record dated [DATE] at 10:05 a.m. indicated Resident #1 was transferred to the hospital emergency department at 10:05 a.m. A hospital history and physical dated [DATE] indicated Resident #1 arrived at the hospital on [DATE] at 10:25 a.m., by ambulance. Resident #1 was described with symptoms of sudden onset of abdominal pain and vomiting, vomited two times the morning of [DATE] with the first episode being mucous and the second episode resembling coffee ground vomitus (an indication of bleeding from the stomach). The physician physical assessment indicated Resident #1 had black vomit on her tongue, was short of breath with abnormal breath sounds described as crackles (abnormal lung sounds, like cellophane being crumpled) in the right and left lungs, and worse on the right. Her oxygen saturation was low and measured 86% (normal oxygen saturation ranges from 95 to 100 percent. Values under 90 percent are considered low) while receiving 3 liters of oxygen per nasal cannula. Resident #1's arterial blood gasses (an accurate test for measuring the blood's oxygen level and other gases) were drawn on [DATE] at 10:45 a.m. and indicated a pO2 (partial pressure of oxygen in arterial blood, a measure of the effectiveness of the lungs ability to oxygenate the blood) of 51.0 (reference range of 80XXX,[DATE].0 mm Hg). Resident #1 was complaining of mild left lower quadrant (below the level of the navel) abdominal pain. Computerized [NAME]ography (CT) of the chest on [DATE] at 11:30 a.m. indicated a combination of [MEDICAL CONDITIONS] (fluid filled lung sacs that decrease oxygen absorption) and/or aspiration (inhaled food or fluids into the air sacs). A stat white blood cell count indicated a result 24.36 10^3/ul outside the normal range of (4XXX,[DATE].80 10^3/ul) Resident #1 was admitted to the hospital. A hospital progress note dated [DATE] at 8:40 a.m., indicated Resident #1's condition worsened overnight with further vomiting and she went into shock requiring pressors (medications used to bring the blood pressure up) and [MEDICAL CONDITION] (Bilevel positive airway pressure a treatment that uses mild air pressure to keep your airways open). The plan of care indicated septic shock, acute [MEDICAL CONDITION]/hypercapnic (low blood oxygen/high blood carbon [MEDICATION NAME]) [MEDICAL CONDITION], possible aspiration pneumonia, hiatal hernia, fluid filled esophagus, NPO (nothing by mouth), and possible upper GI (bleeding from the stomach or bowels) bleed. A hospital discharge summary dated [DATE] indicated Resident #1 was admitted on [DATE] at 12:50 p.m. and discharged [DATE] at 10:04 a.m. The summary indicated Resident #1 presented to the emergency room with altered mental status and [MEDICAL CONDITION] (not enough oxygen in the blood). Her oxygen concentration was in the 80's and required supplemental oxygen. She was positive when tested for the bacteria, staphylococcus aureus and was started on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics to treat bacterial infection). Resident #1's primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED].(low blood sugar), and acute kidney injury. A written statement from the DON, dated [DATE] indicated Resident #2, Resident #1's roommate, told her Resident #1 vomited Saturday night ([DATE]) before going to the hospital on [DATE]. The DON examined the record and found no documentation related to Resident #1 for [DATE] on the ,[DATE] shift. The statement indicated LVN A came to the facility later in the day for an in-service and the DON asked him if Resident #1 had vomited prior to going to the hospital and he confirmed she had. The statement indicated LVN A's story changed several times and he appeared nervous once he found out Resident #1 passed away. The DON's statement indicated LVN A openly admitted he knew he should have called the physician, but he was busy and did not. A written statement by CNA P dated [DATE] indicated on [DATE] at 7:30 p.m. Resident #1 complained of stomach pain and vomited orange colored vomit. CNA P indicated she immediately reported Resident #1's symptoms to the charge nurse. A written statement by LVN C dated [DATE] ([DATE]) indicated Resident #1 complained of vomiting on [DATE] (no time) and LVN C saw clear phlegm in a cup, but no vomit. LVN C indicated Resident #1 did not complain of stomach pain. LVN C indicated she went on break around 6:50 p.m. and another nurse checked Resident #1 and reported clear phlegm and no vomit. LVN C indicated when she returned to work, the next morning on [DATE] for the 6:00 a.m. shift, the night nurse (LVN A) said Resident #1 did not vomit during the night. LVN C indicated she made morning rounds and found Resident #1 with brown coffee ground vomit on her gown at which time she notified the nurse practitioner and received orders to send Resident #1 to the emergency room . A written statement from CNA B, dated [DATE], indicated Resident #2, roommate of Resident #1, informed her Resident #1 was vomiting after she arrived to work at 10:00 p.m., the night of [DATE]. CNA B checked on Resident #1 and then informed LVN A she was vomiting. CNA B then went back and cleaned Resident #1 up, and indicated the vomit looked like congestion at first but by the end of the shift it looked like dark water. CNA B's statement indicated Resident #1 asked for her son to be notified earlier in the shift, but by the end of the shift she was requesting to be sent to the hospital. CNA B indicated each time she checked on Resident #1 she was either vomiting or asleep. A written statement from LVN A, dated [DATE], indicated Resident #2, roommate of Resident #1, came to the nurse's station and told him Resident #1 was vomiting on [DATE] (no time). LVN A went into the room and saw multiple tissues on the bed and in the waste basket. The statement indicated LVN A did not identify vomit on any of the tissues nor in the trashcan. LVN A indicated Resident #2 came to the nurse's station and reported to him, Resident #1 had vomited again. LVN A went into the room and observed clear fluid on the tissue and what appeared to be spit on the tissues. Later LVN A went back into the room to monitor Resident #1 and noticed a small amount of brown vomit around her face. LVN A told the CNA to clean up Resident #1 and told her he would continue to monitor her. The statement indicated LVN A went back into the room later and Resident #1 was resting with eyes closed and no sign of vomit or appearance of distress. LVN A indicated at the end of the shift around 6 a.m. on [DATE], CNA informed him Resident #1 had vomited again and he went and assessed Resident #1. The statement indicated LVN A assessed the resident and informed peer nurse that resident had thrown up and the peer nurse informed LVN A that she had been monitoring Resident #1. The clinical record dated [DATE] from 6:00 a.m. to [DATE] at 6:00 a.m. did not indicate Resident #1 complained of stomach pain or vomiting. The record did not include a notification of the physician for Resident #1's complaints of stomach pain and vomiting. During an interview on [DATE] at 9:35 a.m. the DON said on [DATE] there was documentation that two different nurses had seen Resident #1 and said she had spit up sputum in a cup. She was able to verbalize her needs and use the call light. The DON said CNA B reported Resident #1 vomited a brown coke colored vomit on [DATE] around 11:00 to 11:30 p.m. The DON said LVN A was her nurse and he said she coughed up phlegm the first two times and then vomited up coke-like emesis. The DON said LVN A never called the doctor and did not document anything about Resident #1's condition in the progress notes. The DON said the hospital records indicated Resident #1 had aspiration pneumonia and she died on [DATE] at the hospital. The administrator and DON said video footage from the ,[DATE] shift on [DATE] indicated LVN A went into Resident #1's room at least four times and CNA B went into Resident #1's room at least 6 times during the shift. The DON said on [DATE], LVN C was assigned to Resident #1 on the ,[DATE] shift. Around 9 am LVN C discovered Resident #1 had vomited coffee ground emesis and notified the physician, who ordered Resident #1 be transferred to the hospital. The administrator and DON said on [DATE] Resident #2, Resident #1's roommate, told them Resident #1 had been vomiting on [DATE], the night before she went to the hospital on [DATE]. The DON said she checked Resident #1's record and nothing had been documented about Resident #1 vomiting on [DATE] by LVN [NAME] The DON said on [DATE], LVN A came to the facility for a scheduled in-service and she asked him if Resident #1 had been vomiting the night of [DATE] before she went to the hospital on [DATE], to which he replied, oh yeah. The DON said LVN A admitted he should have called the doctor, but he was too busy. The DON said LVN A was terminated for failing to document care and failing to notify the physician regarding Resident #1's change in status. They said the facility provided in-services for all nursing staff including: monitoring for abuse/neglect, responding to a change in condition, assessing, reporting and notifying physician, documentation, potential signs of GI bleed to include coffee ground emesis, CNA and MA to report nurses not responding to a residents needs and who to report to, recognizing ANE and other reportable events and who to report to, and change in condition. All nursing staff received the in-services. Attempts were made to contact LVN A on [DATE] at 11:40 a.m. and on [DATE] at 7:42 a.m., but he did not answer the phone or return the phone call. During an interview on [DATE] at 3:40 p.m., ADON D and ADON [NAME] said they spoke with LVN A regarding Resident #1's complaints of vomiting on [DATE]. ADON D said LVN A said he should have called the physician, and he should have done more. ADON [NAME] said LVN A said he realized he should have called the physician and Resident #1 would still be here. During an interview on [DATE] at 3:50 p.m., Resident #2 said during the night the nurse came in the room one time and gave Resident #1 a pill and that was when she started throwing up. She said Resident #1 was suffering. During an interview on [DATE] at 9:50 a.m., CNA B said she worked the night shift (10p-6a) on [DATE], the night Resident #1 became ill and started vomiting. CNA B said Resident #2, Resident #1's roommate, wanted someone to come check on Resident #1 because she was worried about her. CNA B said she went into the room about 10:30 p.m., and Resident #1 had vomited a little phlegm. CNA B said she changed Resident #1's gown because it was soiled with emesis. CNA B said when she left the room Resident #1 was talking and not in distress and she left her head elevated. CNA B said she told LVN A at 10:40 p.m., Resident #1 had vomited. CNA B said about 11:30 p.m. Resident #1 vomited in a bath basin and the vomit covered the bottom of the basin. CNA B said the vomit was brown like tea or coffee. She said during the ,[DATE] shift Resident #1 threw up a few times and it was like water and then it was brown like tea or coke. CNA B said at approximately 4:30 -5:00 a.m., Resident #1 seemed to be anxious and asked for her son to be called. CNA B said she reported Resident #1's request to LVN A and he cut her off, saying I've got this. CNA B said she went into Resident #1's room at least ,[DATE] times during the shift, and she saw vomit about 3 times. CNA B said she did not know if LVN A reported to the oncoming nurse. During an interview on [DATE] at 1:45 p.m., Physician M said he was the medical director for the facility and Resident #1's physician. He said he was not notified about Resident #1's vomiting, and he should have been notified. Physician M said the matter was discussed in a Quality Assurance meeting. He said the nurse was terminated and the facility provided an in-service regarding physician notification if a resident has a change in condition. During an interview on [DATE] at 2:34 p.m., LVN C said Resident #1 was spitting up on [DATE] during the ,[DATE] shift. LVN C said Resident #1 described it as vomiting, but it was just spit in a cup. LVN C said she received report from LVN A on the morning of [DATE] for the ,[DATE] shift. LVN C said LVN A reported Resident #1 had pretty much been spitting up but Resident #1 had not vomited during the ,[DATE] shift. LVN C said she saw Resident #1 when she made a round at approximately 6:00 a.m. on [DATE]. She said Resident #1 was asleep, and there was no sign of vomit on her. LVN C said she saw her again at approximately 9:00 a.m. and she was throwing up coffee ground emesis. LVN C said she called the NP on call for Physician M and Resident #1 was transferred to the hospital. LVN C said Resident #1 had not asked her to call her son, but she did so after getting the order to transfer her to the hospital. A Notifying the physician of Change in Status policy, revised (MONTH) 11, 2013, indicated: The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. The nurse is responsible for responding to a change of condition in a timely and effective manner. The nurse document the time of the call to the physician in the clinical record. The nurse will document all attempts to contact the physician in the resident's clinical record. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, they physician orders [REDACTED]. A Documentation policy, revised (MONTH) (YEAR), indicated: The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information is comprehensive and timely and properly signed. Complete documentation in narrative nursing notes in a timely manner. Daily documentation will be required for each shift during and following an acute episode and during physiologic changes or instability. The Texas Board of Nursing website https://www.bon.texas.gov/rr_current/,[DATE].asp accessed [DATE] indicated the following: .RULE 217.11 Standards of Nursing Practice The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; It was determined these failures placed Resident #1 in an Immediate Jeopardy situation from [DATE] to [DATE]. The following actions were implemented by the facility to correct the non-compliance from [DATE] to [DATE]: *Inservice Records dated [DATE] indicated: Training was provided on assessments, prevention of aspiration and aspiration pneumonia. Risk for aspiration was identified as increased in elders, with swallowing and coughing deficits. Signs and symptoms of aspiration pneumonia included cough which may or may not bring up mucus, pink or frothy sputum, and trouble swallowing. Training was provided to 18 licensed nurses on reporting changes of condition and SBAR's. The Inservice indicated a change in condition is any symptom, sign or apparent discomfort that is acute or sudden, a marked change from usual symptoms and unrelieved by measures already prescribed. Training was provided 18 CNAs on responding to resident needs and reporting nursing staff to the DON, ADON, and administrator if the CNA believes the nurse is not responding appropriately. The facility initiated monitoring indicated the following: * A weekly monitoring tool dated [DATE] indicated ,[DATE] staff members per week, would be asked situational questions related to the concern of neglect regarding Resident #1. Interviews included what you would do if .? How would you respond to .? Nurses were interviewed weekly for appropriate responses. Resident assessment, physician notification and accurate documentation of assessment, interventions, and resident response to interventions were included in nursing responses. *A monitoring tool indicated 5 CNA's a week were asked how they would respond to a situation where the nursing staff did not provide care to a resident. CNAs indicated they would notify another nurse of their concern, and the DON/ADON as needed. The CNAs indicated they would report any suspected abuse immediately. * A monitoring tool indicated 5 residents a week were interviewed for staff treatment with an indicator to follow up with any negative responses. * A monitoring tool indicated incident and events were reviewed for appropriate staff responses to resident needs or any indication of neglect. The monitoring included resident assessment and documentation as well as physician notification. * Monitoring of ,[DATE] staff per week were observed providing resident care to ensure safe care delivery: Medication administration, point of care glucose testing, gastric tube feeding, incontinent care, and resident transfer assist were included in monitoring. Four CNAs were interviewed by the surveyor and indicated they were educated on when to notify the charge nurse or DON/administrator if a resident had a change of condition and would notify the assigned nurse or DON if a licensed nurse was not providing the necessary care needed after a report of change of condition. During an interview on [DATE] at 2:45 p.m., CNA P said if a resident was sick and not receiving appropriate treatment from their assigned nurse, she would get another nurse to come help, and that the facility had recently provided an in-service on this topic. During an interview on [DATE] at 2:50 p.m., CNA K said if a resident was not receiving appropriate treatment from their nurse he would call the DON and report it. He said the facility had recently provided an in-service on this topic. During an interview on [DATE] at 2:55 p.m., CNA J said she would call the DON or administrator if a nurse was not providing appropriate treatment, and that it had been covered in an in-service. During an interview on [DATE] at 3:00 p.m., CNA L said if a resident were not getting the appropriate treatment she would contact another nurse or call the DON or administrator is she had to. She said this was covered in a recent in-service. During an interview on [DATE] at 1:30 p.m., the DON said nursing competency is ensured by training on hire and as needed, as well as completion of the Nursing Proficiency Audit. She said the Nursing Proficiency Audit is completed during orientation and annually. Three LVNs were interviewed by the surveyor and indicated they had been in serviced on resident changes of condition, notification of the physician, assessment and emergency interventions. During an interview on [DATE] at 1:28 p.m., LVN F said if a resident was experiencing vomiting, shortness of breath, or other distress she would immediately assess the resident, evaluate whether emergency interventions were indicated and call the doctor. LVN F said she completed the Nurse Proficiency Audit when she was hired and annually. During an interview on [DATE] at 1:34 p.m., LVN N said if a resident was in distress the first action would be to assess the resident, then notify the doctor. LVN N said vomiting would be a reason to notify the physician. She said she was familiar with the Nurse Proficiency Audit form. LVN N said they were done annually, and when hired. During an interview on [DATE] at 1:39 p.m., LVN O said if a resident had vomiting she would immediately assess the resident and then position them, so they wouldn't aspirate. She said she would call the doctor, and in cases of extreme distress would call 911 immediately. LVN O said she was familiar with the Nurse Proficiency Audit. LVN O said the Nurse Proficiency Audit was completed on hire and annually. She said skills are observed and guidance given as needed. During an interview with the DON on [DATE] at 12:35 p.m., she said Resident #1 was transferred to the hospital on [DATE] at 10:05 a.m. She said all in-services related to the incident were completed at an unspecified time on [DATE]. Three other residents (Resident's #s 3, 4, & 5) who had experienced recent changes of condition were reviewed by the surveyor for physician notification and indicated all three received timely assessment and intervention, including physician notification and transfer to the hospital.

Based on interview and record review, the facility failed to ensure treatment and care was provided in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 4 residents reviewed for care and services. (Resident #1) LVN A and LVN C did not implement Resident #1's comprehensive care plan to assess and notify the physician for signs and symptoms of vomiting. Resident #1 complained of vomiting on [DATE] at 7:30 p.m. and had repeated episodes of vomiting through the night. On [DATE] at 10:05 a.m. Resident #1 was transferred to the hospital emergency room where she was diagnosed with [REDACTED]. In severe cases, one or more organs fail. In the worst cases, blood pressure drops, and the heart weakens, leading to septic shock.) Resident #1 died on [DATE]. This was determined to be past non-compliance that existed from [DATE] and was corrected on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who experienced a change of condition at risk of increased injury, delayed care, and death. Findings included: Physician orders [REDACTED].#1 was an [AGE] year-old female, admitted [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was at risk for aspiration and orders on [DATE] included aspiration precautions to keep the head of bed elevated 30 to 45 degrees. The most recent MDS dated [DATE] indicated Resident #1 had severe cognitive impairment, minimal difficulty hearing, clear speech, was usually understood, and sometimes understood others. She required extensive assistance of two staff with transfers, bed mobility, dressing, toileting and personal hygiene. Dysphagia was listed under additional active [DIAGNOSES REDACTED]. A care plan initiated [DATE] and revised [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. Interventions included to monitor/document/ notify physician for changes in lung sounds on auscultation i.e., crackles. Monitor/document/ notify physician for heartburn, nausea and vomiting or other signs of [MEDICAL CONDITION]. The care plan further indicated Resident #1's [DIAGNOSES REDACTED]. The care plan indicated Resident #1 was at risk for nutritional deficit due to [MEDICAL CONDITION] and therapeutic diet. Interventions included: Monitor/document/report to MD PRN (as needed) for signs and symptoms of dysphagia- pocketing, choking, coughing, drooling, holding food in mouth. The provider investigation report dated [DATE] indicated on [DATE] at 5:39 p.m. a self-report of neglect was made to the state agency for Resident #1. On [DATE] around 4:00 p.m. CNA B alleged LVN A observed Resident #1 vomiting multiple times during the 10:00 p.m. to 6:00 a.m. shift on [DATE] and [DATE]. The report indicated LVN A did not notify Resident #1's physician of the repeated episodes of vomiting, nor had LVN A documented an assessment of Resident #1's change in condition in the clinical record. The investigation further indicated that Resident #1 had episodes of coughing up and vomiting several times on [DATE] between 2:00 p.m. and 10:00 p.m. and LVN C did not document the changes in the clinical record or notify the physician. A MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A TAR dated (MONTH) 2019 indicated Resident #1 was on aspiration precautions-head of bed elevated 30 to 45 degrees each shift for prevention. Nursing initialed from [DATE] through [DATE] on days, evening and nights as performed. A SBAR (situation, background, assessment, and recommendation) communication record dated [DATE] indicated Resident #1 had abdominal/ GI (gastrointestinal) changes, GI bleed, described as coffee ground vomit onset [DATE], with primary [DIAGNOSES REDACTED]. The nurse practitioner was notified on [DATE] at 9:20 a.m. and orders were received to send Resident #1 to the emergency department for evaluation and treatment. Her vital signs indicated a blood pressure of ,[DATE], temperature of 97.9, pulse of 89, and respiratory rate of 20. Her oxygen saturation was 95% on room air. A transfer record dated [DATE] at 10:05 a.m. indicated Resident #1 was transferred to the hospital emergency department. A hospital history and physical dated [DATE] indicated Resident #1 arrived at the hospital on [DATE] at 10:25 a.m., by ambulance. Resident #1 was described with symptoms of sudden onset of abdominal pain and vomiting, vomited two times the morning of [DATE] with the first episode being mucous and the second episode resembling coffee ground vomitus (an indication of bleeding from the stomach). The physician physical assessment indicated Resident #1 had black vomit on her tongue, was short of breath with abnormal breath sounds described as crackles (abnormal lung sounds, like cellophane being crumpled) in the right and left lungs, and worse on the right. Her oxygen saturation was low and measured 86% (normal oxygen saturation ranges from 95 to 100 percent. Values under 90 percent are considered low) while receiving 3 liters of oxygen per nasal cannula. Resident #1's arterial blood gasses (an accurate test for measuring the blood's oxygen level and other gases) were drawn on [DATE] at 10:45 a.m. and indicated a pO2 (partial pressure of oxygen in arterial blood, a measure of the effectiveness of the lungs ability to oxygenate the blood) of 51.0 (reference range of 80XXX,[DATE].0 mm Hg). Resident #1 was complaining of mild left lower quadrant (below the level of the navel) abdominal pain. Computerized [NAME]ography (CT) of the chest on [DATE] at 11:30 a.m. indicated a combination of [MEDICAL CONDITIONS] (fluid filled lung sacs that decrease oxygen absorption) and/or aspiration (inhaled food or fluids into the air sacs). The CT also indicated a large hiatal hernia was present and the stomach was in the left chest cavity. A stat white blood cell count indicated a result 24.36 10^3/ul outside the normal range of (4XXX,[DATE].80 10^3/ul) Resident #1 was admitted to the hospital. A hospital progress note dated [DATE] at 8:40 a.m., indicated Resident #1's condition worsened overnight with further vomiting and she went into shock requiring pressors (medications used to bring the blood pressure up) and [MEDICAL CONDITION] (Bilevel positive airway pressure a treatment that uses mild air pressure to keep your airways open). The plan of care indicated septic shock, acute [MEDICAL CONDITION]/hypercapnic (low blood oxygen/high blood carbon [MEDICATION NAME]) [MEDICAL CONDITION], possible aspiration pneumonia, hiatal hernia, fluid filled esophagus, NPO (nothing by mouth), and possible upper GI (gastrointestinal) bleed. A hospital discharge summary dated [DATE] indicated Resident #1 was admitted on [DATE] at 12:50 p.m. and discharged [DATE] at 10:04 a.m. The summary indicated Resident #1 presented to the emergency room with altered mental status and [MEDICAL CONDITION] (not enough oxygen in the blood). Her oxygen concentration was in the 80's and required supplemental oxygen. She was positive when tested for the bacteria, staphylococcus aureus and was started on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics to treat bacterial infection). Resident #1's primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED].(low blood sugar), and acute kidney injury. A written statement from the DON, dated [DATE] indicated Resident #2, Resident #1's roommate, told her Resident #1 vomited Saturday night ([DATE]) before going to the hospital on [DATE]. The DON examined the record and found no documentation related to Resident #1 for [DATE] on the ,[DATE] shift. The statement indicated LVN A came to the facility later in the day for an in-service and the DON asked him if Resident #1 had vomited prior to going to the hospital and he confirmed she had. The statement indicated LVN A's story changed several times and he appeared nervous once he found out Resident #1 passed away. The DON's statement indicated LVN A openly admitted he knew he should have called the physician, but he was busy and did not. A written statement by CNA P dated [DATE] indicated on [DATE] at 7:30 p.m. Resident #1 complained of stomach pain and vomited orange colored vomit. CNA P indicated she immediately reported Resident #1's symptoms to the charge nurse. A written statement by LVN C dated [DATE] ([DATE]) indicated Resident #1 complained of vomiting on [DATE] (no time) and LVN C saw clear phlegm in a cup, but no vomit. LVN C indicated Resident #1 did not complain of stomach pain. LVN C indicated she went on break around 6:50 p.m. and another nurse checked Resident #1 and reported clear phlegm and no vomit. LVN C indicated when she returned to work, the next morning on [DATE] for the 6:00 a.m. shift, the night nurse (LVN A) said Resident #1 did not vomit during the night. LVN C indicated she made morning rounds and found Resident #1 with brown coffee ground vomit on her gown at which time she notified the nurse practitioner and received orders to send Resident #1 to the emergency room . A written statement from CNA B, dated [DATE], indicated Resident #2, roommate of Resident #1, informed her Resident #1 was vomiting after she arrived to work at 10:00 p.m., the night of [DATE]. CNA B checked on Resident #1 and then informed LVN A she was vomiting. CNA B then went back and cleaned Resident #1 up, and indicated the vomit looked like congestion at first but by the end of the shift it looked like dark water. CNA B's statement indicated Resident #1 asked for her son to be notified earlier in the shift, but by the end of the shift she was requesting to be sent to the hospital. CNA B indicated each time she checked on Resident #1 she was either vomiting or asleep. A written statement from LVN A, dated [DATE], indicated Resident #2, roommate of Resident #1, came to the nurse's station and told him Resident #1 was vomiting on [DATE] (no time). LVN A went into the room and saw multiple tissues on the bed and in the waste basket. The statement indicated LVN A did not identify vomit on any of the tissues nor in the trashcan. LVN A indicated Resident #2 came to the nurse's station and reported to him, Resident #1 had vomited again. LVN A went into the room and observed clear fluid on the tissue and what appeared to be spit on the tissues. Later LVN A went back into the room to monitor Resident #1 and noticed a small amount of brown vomit around her face. LVN A told the CNA to clean up Resident #1 and told her he would continue to monitor her. The statement indicated LVN A went back into the room later and Resident #1 was resting with eyes closed and no sign of vomit or appearance of distress. LVN A indicated at the end of the shift around 6 a.m. on [DATE], CNA informed him Resident #1 had vomited again and he went and assessed Resident #1. The statement indicated LVN A assessed the resident and informed peer nurse that resident had thrown up and the peer nurse informed LVN A that she had been monitoring Resident #1. The clinical record dated [DATE] from 6:00 a.m. to [DATE] at 6:00 a.m. did not indicate Resident #1 complained of stomach pain or vomiting. The record did not include an assessment of Resident #1's complaints or physician notification. During an interview on [DATE] at 9:35 a.m. the DON said on [DATE] there was documentation that two different nurses had seen Resident #1 and said she had spit up sputum in a cup. She was able to verbalize her needs and use the call light. The DON said CNA B reported Resident #1 vomited a brown coke colored vomit on [DATE] around 11:00 to 11:30 p.m. The DON said LVN A was her nurse and he said she coughed up phlegm the first two times and then vomited up coke-like emesis. The DON said LVN A never called the physician and did not document anything about Resident #1's condition in the progress notes. The DON said the hospital records indicated Resident #1 had aspiration pneumonia and she died on [DATE] at the hospital. The administrator and DON said video footage from the ,[DATE] shift on [DATE] indicated LVN A went into Resident #1's room at least four times and CNA B went into Resident #1's room at least 6 times during the shift. The DON said on [DATE], LVN C was assigned to Resident #1 on the ,[DATE] shift. Around 9 am LVN C discovered Resident #1 had vomited coffee ground emesis and notified the physician, who ordered Resident #1 be transferred to the hospital. The administrator and DON said on [DATE] Resident #2, Resident #1's roommate, told them Resident #1 had been vomiting on [DATE], the night before she went to the hospital on [DATE]. The DON said she checked Resident #1's record and nothing had been documented about Resident #1 vomiting on [DATE] by LVN [NAME] The DON said on [DATE], LVN A came to the facility for a scheduled in-service and she asked him if Resident #1 had been vomiting the night of [DATE] before she went to the hospital on [DATE], to which he replied, oh yeah. The DON said LVN A admitted he should have called the doctor, but he was too busy. The DON said LVN A was terminated for failing to document care and failing to notify the physician regarding Resident #1's change in status. They said the facility provided in-services for all nursing staff including: monitoring for abuse/neglect, responding to a change in condition, assessing, reporting and notifying physician, documentation, potential signs of GI bleed to include coffee ground emesis, CNA and MA to report nurses not responding to a residents needs and who to report to, recognizing ANE and other reportable events and who to report to, and change in condition. All nursing staff received the in-services. Attempts were made to contact LVN A on [DATE] at 11:40 a.m. and on [DATE] at 7:42 a.m., but he did not answer the phone or return the phone call. Personnel records for LVN A indicated appropriate background checks were conducted prior to employment. An Employee Disciplinary Report dated [DATE] indicated LVN A was terminated for violating the company policy regarding abuse/neglect. A Personnel Action Form dated [DATE] indicated LVN A refused to return to the facility and indicated he acknowledged verbally on the phone he was being terminated and felt it was deserved. LVN A was suspended on [DATE] and terminated on [DATE] for neglect. During an interview on [DATE] at 3:40 p.m., ADON D and ADON [NAME] said they spoke with LVN A regarding Resident #1's vomiting on [DATE]. ADON D said LVN A said he should have called the physician, and he should have done more. ADON [NAME] said LVN A said he realized he should have called the physician and Resident #1 would still be here. During an interview on [DATE] at 3:50 p.m., Resident #2 said, during the night the nurse came in the room one time and gave Resident #1 a pill and that was when she started throwing up. She said Resident #1 was suffering. During an interview on [DATE] at 9:50 a.m., CNA B said she worked the night shift (10p-6a) on [DATE], the night Resident #1 became ill and started vomiting. CNA B said Resident #2, Resident #1's roommate, wanted someone to come check on Resident #1 because she was worried about her. CNA B said she went into the room about 10:30 p.m., and Resident #1 had vomited a little phlegm. CNA B said she changed Resident #1's gown because it was soiled with emesis. CNA B said when she left the room Resident #1 was talking and not in distress and she left her head elevated. CNA B said she told LVN A at 10:40 p.m., Resident #1 had vomited. CNA B said about 11:30 p.m. Resident #1 vomited in a bath basin and the vomit covered the bottom of the basin. CNA B said the vomit was brown like tea or coffee. She said during the ,[DATE] shift Resident #1 threw up a few times and it was like water and then it was brown like tea or coke. CNA B said at approximately 4:30 -5:00 a.m., Resident #1 seemed to be anxious and asked for her son to be called. CNA B said she reported Resident #1's request to LVN A and he cut her off, saying I've got this. CNA B said she went into Resident #1's room at least ,[DATE] times during the shift, and she saw vomit about 3 times. CNA B said she did not know if LVN A reported to the oncoming nurse. During an interview on [DATE] at 1:45 p.m., Physician M said he was the medical director for the facility and Resident #1's physician. He said he was not notified about Resident #1's vomiting, and he should have been notified. Physician M said the matter was discussed in a Quality Assurance meeting. He said the nurse was terminated and the facility provided an in-service regarding physician notification if a resident has a change in condition. During an interview on [DATE] at 2:34 p.m., LVN C said Resident #1 was spitting up on [DATE] during the ,[DATE] shift. LVN C said Resident #1 described it as vomiting, but it was just spit in a cup. LVN C said she received report from LVN A on the morning of [DATE] for the ,[DATE] shift. LVN C said LVN A reported Resident #1 had pretty much been spitting up but Resident #1 had not vomited during the ,[DATE] shift. LVN C said she saw Resident #1 when she made a round at approximately 6:00 a.m. on [DATE]. She said Resident #1 was asleep, and there was no sign of vomit on her. LVN C said she saw her again at approximately 9:00 a.m. and she was throwing up coffee ground emesis. LVN C said she called the NP on call for Physician M and Resident #1 was transferred to the hospital. LVN C said Resident #1 had not asked her to call her son, but she did so after getting the order to transfer her to the hospital. A Notifying the physician of Change in Status policy, revised (MONTH) 11, 2013, indicated: The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. The nurse is responsible for responding to a change of condition in a timely and effective manner. The nurse document the time of the call to the physician in the clinical record. The nurse will document all attempts to contact the physician in the resident's clinical record. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, they physician orders [REDACTED]. A Documentation policy, revised (MONTH) (YEAR), indicated: The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information is comprehensive and timely and properly signed. Complete documentation in narrative nursing notes in a timely manner. Daily documentation will be required for each shift during and following an acute episode and during physiologic changes or instability. The Texas Board of Nursing website https://www.bon.texas.gov/rr_current/,[DATE].asp accessed [DATE] indicated the following: .RULE 217.11 Standards of Nursing Practice The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status . It was determined these failures placed Resident #1 in an Immediate Jeopardy situation from [DATE] to [DATE]. The following actions were implemented by the facility to correct the non-compliance from [DATE] to [DATE]: *Inservice Records dated [DATE] indicated: Training was provided to 18 licensed nursing staff on reporting changes of condition and SBAR's. The Inservice indicated a change in condition is any symptom, sign or apparent discomfort that is acute or sudden, a marked change from usual symptoms and unrelieved by measures already prescribed. Recognizing residents at risk for aspiration, prevention, and signs and symptoms of aspiration pneumonia were provided. The risk for aspiration was identified as increased in elders with swallowing and/or coughing deficits. Signs and symptoms of aspiration pneumonia included cough which may or may not bring up mucus, pink or frothy sputum, and trouble swallowing. Training was provided 18 CNAs on responding to resident needs and reporting nursing staff to the DON, ADON, and administrator if the CNA believes the nurse is not responding appropriately. The facility initiated monitoring indicated the following: * A weekly monitoring tool dated [DATE] indicated ,[DATE] staff members per week, would be asked situational questions related to the concern of neglect regarding Resident #1. Interviews included what you would do if .? How would you respond to .? Nurses were interviewed weekly for appropriate responses. Resident assessment, physician notification and accurate documentation of assessment, interventions, and resident response to interventions were included in nursing responses. *A monitoring tool indicated 5 CNA's a week were asked how they would respond to a situation where the nursing staff did not provide care to a resident. CNAs indicated they would notify another nurse of their concern, and the DON/ADON as needed. The CNAs indicated they would report any suspected abuse immediately. * A monitoring tool indicated 5 residents a week were interviewed for staff treatment with an indicator to follow up with any negative responses. * A monitoring tool indicated incident and events were reviewed for appropriate staff responses to resident needs or any indication of neglect. The monitoring included resident assessment and documentation as well as physician notification. * ,[DATE] staff per week were observed providing resident care to ensure safe care delivery: Medication administration, point of care glucose testing, gastric tube feeding, incontinent care, and resident transfer assist were included in monitoring. Four CNAs were interviewed by the surveyor and indicated they were educated on when to notify the charge nurse or DON/administrator if a resident had a change of condition and would notify the assigned nurse or DON if a licensed nurse was not providing the necessary care needed after a report of change of condition. During an interview on [DATE] at 2:45 p.m., CNA P said if a resident was sick and not receiving appropriate treatment from their assigned nurse, she would get another nurse to come help, and that the facility had recently provided an in-service on this topic. During an interview on [DATE] at 2:50 p.m., CNA K said if a resident was not receiving appropriate treatment from their nurse he would call the DON and report it. He said the facility had recently provided an in-service on this topic. During an interview on [DATE] at 2:55 p.m., CNA J said she would call the DON or administrator if a nurse was not providing appropriate treatment, and that it had been covered in an in-service. During an interview on [DATE] at 3:00 p.m., CNA L said if a resident were not getting the appropriate treatment she would contact another nurse or call the DON or administrator is she had to. She said this was covered in a recent in-service. During an interview on [DATE] at 1:30 p.m., the DON said nursing competency is ensured by training on hire and as needed, as well as completion of the Nursing Proficiency Audit. She said the Nursing Proficiency Audit is completed during orientation and annually. Three LVNs were interviewed by the surveyor and indicated they had been in serviced on resident changes of condition, notification of the physician, assessment and emergency interventions. During an interview on [DATE] at 1:28 p.m., LVN F said if a resident was experiencing vomiting, shortness of breath, or other distress she would immediately assess the resident, evaluate whether emergency interventions were indicated and call the doctor. LVN F said she completed the Nurse Proficiency Audit when she was hired and annually. During an interview on [DATE] at 1:34 p.m., LVN N said if a resident was in distress the first action would be to assess the resident, then notify the doctor. LVN N said vomiting would be a reason to notify the physician. She said she was familiar with the Nurse Proficiency Audit form. LVN N said they were done annually, and when hired. During an interview on [DATE] at 1:39 p.m., LVN O said if a resident had vomiting she would immediately assess the resident and then position them, so they wouldn't aspirate. She said she would call the doctor, and in cases of extreme distress would call 911 immediately. LVN O said she was familiar with the Nurse Proficiency Audit. LVN O said the Nurse Proficiency Audit was completed on hire and annually. She said skills are observed and guidance given as needed. During an interview with the DON on [DATE] at 12:35 p.m., she said Resident #1 was transferred to the hospital on [DATE] at 10:05 a.m. She said all in-services related to the incident were completed at an unspecified time on [DATE]. Three other residents (Resident's #s 3, 4, & 5) who had experienced recent changes of condition were reviewed for physician notification and indicated all three received timely assessment and intervention, including physician notification and transfer to the hospital.

Based on interview and record review, the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices, were complete and accurately documented, for 1 of 4 residents reviewed for medical records. (Resident #1) Nursing staff did not document in Resident #1's clinical records her complaints of vomiting, assessment or nursing interventions on [DATE] and [DATE]. Resident #1 was transferred to the emergency department on [DATE] at 10:05 a.m. and was diagnosed with [REDACTED]. Resident #1 died on [DATE]. This was determined to be past non-compliance that existed from [DATE] and was corrected on [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for unrecognized changes in health status and not being provided necessary care and services. Findings included: Physician orders [REDACTED].#1 was an [AGE] year-old female, admitted [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was at risk for aspiration and orders on [DATE] included aspiration precautions to keep the head of bed elevated 30 to 45 degrees. The most recent MDS dated [DATE] indicated Resident #1 had severe cognitive impairment, minimal difficulty hearing, clear speech, was usually understood, and sometimes understood others. She required extensive assistance of two staff with transfers, bed mobility, dressing, toileting and personal hygiene. Dysphagia was listed under additional active [DIAGNOSES REDACTED]. A care plan initiated [DATE] and revised [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. Interventions included to monitor/document/ notify physician for nausea and vomiting or other signs of [MEDICAL CONDITION]. The care plan indicated Resident #1 was at risk for nutritional deficit due to [MEDICAL CONDITION] and therapeutic diet. Interventions included: Monitor/document/report to MD PRN (as needed) for signs and symptoms of dysphagia- pocketing, choking, coughing, drooling, holding food in mouth. A SBAR (situation, background, assessment, and recommendation) communication record dated [DATE] indicated Resident #1 had abdominal/ GI (gastrointestinal) changes, GI bleed, described as coffee ground vomit onset [DATE], with primary [DIAGNOSES REDACTED]. The nurse practitioner was notified on [DATE] at 9:20 a.m. and orders were received to send Resident #1 to the emergency department for evaluation and treatment. Her vital signs indicated a blood pressure of ,[DATE], temperature of 97.9, pulse of 89, and respiratory rate of 20. Her oxygen saturation was 95% on room air. A transfer record dated [DATE] at 10:05 a.m. indicated Resident #1 was transferred to the hospital emergency department. A hospital history and physical dated [DATE] indicated Resident #1 arrived at the hospital on [DATE] at 10:25 a.m., by ambulance. Resident #1 was described with symptoms of sudden onset of abdominal pain and vomiting, vomited two times the morning of [DATE] with the first episode being mucous and the second episode resembling coffee ground vomitus (an indication of bleeding from the stomach). The physician physical assessment indicated Resident #1 had black vomit on her tongue, was short of breath with abnormal breath sounds described as crackles (abnormal lung sounds, like cellophane being crumpled) in the right and left lungs, and worse on the right. Her oxygen saturation was low and measured 86% (normal oxygen saturation ranges from 95 to 100 percent. Values under 90 percent are considered low) while receiving 3 liters of oxygen per nasal cannula. Resident #1's arterial blood gasses (an accurate test for measuring the blood's oxygen level and other gases) were drawn on [DATE] at 10:45 a.m. and indicated a pO2 (partial pressure of oxygen in arterial blood, a measure of the effectiveness of the lungs ability to oxygenate the blood) of 51.0 (reference range of 80XXX,[DATE].0 mm Hg). Resident #1 was complaining of mild left lower quadrant (below the level of the navel) abdominal pain. Computerized [NAME]ography (CT) of the chest on [DATE] at 11:30 a.m. indicated a combination of [MEDICAL CONDITIONS] (fluid filled lung sacs that decrease oxygen absorption) and/or aspiration (inhaled food or fluids into the air sacs). The CT also indicated a large hiatal hernia was present and the stomach was in the left chest cavity. A stat white blood cell count indicated a result 24.36 10^3/ul outside the normal range of (4XXX,[DATE].80 10^3/ul) Resident #1 was admitted to the hospital. A hospital discharge summary dated [DATE] indicated Resident #1 was admitted on [DATE] at 12:50 p.m. and discharged [DATE] at 10:04 a.m. The summary indicated Resident #1 presented to the emergency room with altered mental status and [MEDICAL CONDITION] (not enough oxygen in the blood). Her oxygen concentration was in the 80's and required supplemental oxygen. She was positive when tested for the bacteria, staphylococcus aureus and was started on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics to treat bacterial infection). Resident #1's primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED].(low blood sugar), and acute kidney injury. The provider investigation report dated [DATE] indicated on [DATE] at 5:39 p.m. a self-report of neglect was made to the state agency for Resident #1. On [DATE] around 4:00 p.m. CNA B alleged LVN A observed Resident #1 vomiting multiple times during the 10:00 p.m. to 6:00 a.m. shift on [DATE] and [DATE]. The report indicated LVN A did not notify Resident #1's physician of the repeated episodes of vomiting, nor had LVN A documented an assessment of Resident #1's change in condition in the clinical record. The investigation further indicated that Resident #1 had episodes of coughing up and vomiting several times on [DATE] between 2:00 p.m. and 10:00 p.m. and LVN C did not document the changes in the clinical record or notify the physician. The clinical record for Resident #1 dated [DATE] from 6:00 a.m. to [DATE] to 6:00 a.m. did not include LVN A nor LVN C's clinical assessment and documentation concerning Resident #1's complaints of vomiting. A written statement by CNA P dated [DATE] indicated on [DATE] at 7:30 p.m. Resident #1 complained of stomach pain and vomited orange colored vomit. CNA P indicated she immediately reported Resident #1's symptoms to the charge nurse. A written statement by LVN C dated [DATE] ([DATE]) indicated Resident #1 complained of vomiting on [DATE] (no time) and LVN C saw clear phlegm in a cup, but no vomit. LVN C indicated Resident #1 did not complain of stomach pain. During an interview on [DATE] at 2:34 p.m., LVN C said Resident #1 was spitting up on [DATE] during the ,[DATE] shift. LVN C said Resident #1 described it as vomiting, but it was just spit in a cup. A written statement from CNA B, dated [DATE], indicated Resident #2, roommate of Resident #1, informed her Resident #1 was vomiting after she arrived to work at 10:00 p.m., the night of [DATE]. CNA B checked on Resident #1 and then informed LVN A she was vomiting. CNA B then went back and cleaned Resident #1 up, and indicated the vomit looked like congestion at first but by the end of the shift it looked like dark water. CNA B's statement indicated Resident #1 asked for her son to be notified earlier in the shift, but by the end of the shift she was requesting to be sent to the hospital. CNA B indicated each time she checked on Resident #1 she was either vomiting or asleep. During an interview on [DATE] at 9:50 a.m., CNA B said she worked the night shift (10p-6a) on [DATE], the night Resident #1 became ill and started vomiting. CNA B said she told LVN A at 10:40 p.m., Resident #1 had vomited. CNA B said about 11:30 p.m. Resident #1 vomited in a bath basin and the vomit covered the bottom of the basin. CNA B said the vomit was brown like tea or coffee. A written statement from LVN A, dated [DATE], indicated Resident #2, roommate of Resident #1, came to the nurse's station and told him Resident #1 was vomiting on [DATE] (no time). LVN A went into the room and saw multiple tissues on the bed and in the waste basket. The statement indicated LVN A did not identify vomit on any of the tissues nor in the trashcan. LVN A indicated Resident #2 came to the nurse's station and reported to him, Resident #1 had vomited again. LVN A went into the room and observed clear fluid on the tissue and what appeared to be spit on the tissues. Later LVN A went back into the room to monitor Resident #1 and noticed a small amount of brown vomit around her face. LVN A told the CNA to clean up Resident #1 and told her he would continue to monitor her. The statement indicated LVN A went back into the room later and Resident #1 was resting with eyes closed and no sign of vomit or appearance of distress. LVN A indicated at the end of the shift around 6 a.m. on [DATE], CNA informed him Resident #1 had vomited again and he went and assessed Resident #1. The statement indicated LVN A assessed the resident and informed peer nurse that resident had thrown up and the peer nurse informed LVN A that she had been monitoring Resident #1. During an interview on [DATE] at 9:35 a.m. the DON said LVN A never called the physician and did not document anything about Resident #1's condition in the progress notes on [DATE] or [DATE]. A Documentation policy, revised (MONTH) (YEAR), indicated: The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information is comprehensive and timely and properly signed. Complete documentation in narrative nursing notes in a timely manner. Daily documentation will be required for each shift during and following an acute episode and during physiologic changes or instability. The Texas Board of Nursing website https://www.bon.texas.gov/rr_current/,[DATE].asp accessed [DATE] indicated the following: .RULE 217.11 Standards of Nursing Practice- The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status . It was determined these failures placed Resident #1 in an Immediate Jeopardy situation from [DATE] to [DATE]. The following actions were implemented by the facility to correct the non-compliance from [DATE] to [DATE]: *Inservice Records dated [DATE] indicated: Training was provided to 18 licensed nursing staff on reporting changes of condition and SBAR's. The Inservice indicated a change in condition is any symptom, sign or apparent discomfort that is acute or sudden, a marked change from usual symptoms and unrelieved by measures already prescribed. Recognizing residents at risk for aspiration, prevention, and signs and symptoms of aspiration pneumonia were provided. The risk for aspiration was identified as increased in elders with swallowing and/or coughing deficits. Signs and symptoms of aspiration pneumonia included cough which may or may not bring up mucus, pink or frothy sputum, and trouble swallowing. Training was provided 18 CNAs on responding to resident needs and reporting nursing staff to the DON, ADON, and administrator if the CNA believes the nurse is not responding appropriately. The facility initiated monitoring indicated the following: * A weekly monitoring tool dated [DATE] indicated ,[DATE] staff members per week, would be asked situational questions related to the concern of neglect regarding Resident #1. Interviews included what you would do if .? How would you respond to .? Nurses were interviewed weekly for appropriate responses. Resident assessment, physician notification and accurate documentation of assessment, interventions, and resident response to interventions were included in nursing responses. *A monitoring tool indicated 5 CNA's a week were asked how they would respond to a situation where the nursing staff did not provide care to a resident. CNAs indicated they would notify another nurse of their concern, and the DON/ADON as needed. The CNAs indicated they would report any suspected abuse immediately. * A monitoring tool indicated 5 residents a week were interviewed for staff treatment with an indicator to follow up with any negative responses. * A monitoring tool indicated incident and events were reviewed for appropriate staff responses to resident needs or any indication of neglect. The monitoring included resident assessment and documentation as well as physician notification. * A monitoring tool indicated ,[DATE] staff per week were observed providing resident care to ensure safe care delivery: Medication administration, point of care glucose testing, gastric tube feeding, incontinent care, and resident transfer assist were included in monitoring. Four CNAs were interviewed by the surveyor and indicated they were educated on when to notify the charge nurse or DON/administrator if a resident had a change of condition and would notify the assigned nurse or DON if a licensed nurse was not providing the necessary care needed after a report of change of condition. During an interview on [DATE] at 2:45 p.m., CNA P said if a resident was sick and not receiving appropriate treatment from their assigned nurse, she would get another nurse to come help, and that the facility had recently provided an in-service on this topic. During an interview on [DATE] at 2:50 p.m., CNA K said if a resident was not receiving appropriate treatment from their nurse he would call the DON and report it. He said the facility had recently provided an in-service on this topic. During an interview on [DATE] at 2:55 p.m., CNA J said she would call the DON or administrator if a nurse was not providing appropriate treatment, and that it had been covered in an in-service. During an interview on [DATE] at 3:00 p.m., CNA L said if a resident were not getting the appropriate treatment she would contact another nurse or call the DON or administrator is she had to. She said this was covered in a recent in-service. During an interview on [DATE] at 1:30 p.m., the DON said nursing competency is ensured by training on hire and as needed, as well as completion of the Nursing Proficiency Audit. She said the Nursing Proficiency Audit is completed during orientation and annually. Three LVNs were interviewed by the surveyor and indicated they had been in serviced on resident changes of condition, notification of the physician, assessment and emergency interventions. During an interview on [DATE] at 1:28 p.m., LVN F said if a resident was experiencing vomiting, shortness of breath, or other distress she would immediately assess the resident, evaluate whether emergency interventions were indicated and call the doctor. LVN F said she completed the Nurse Proficiency Audit when she was hired and annually. During an interview on [DATE] at 1:34 p.m., LVN N said if a resident was in distress the first action would be to assess the resident, then notify the doctor. LVN N said vomiting would be a reason to notify the physician. She said she was familiar with the Nurse Proficiency Audit form. LVN N said they were done annually, and when hired. During an interview on [DATE] at 1:39 p.m., LVN O said if a resident had vomiting she would immediately assess the resident and then position them, so they wouldn't aspirate. She said she would call the doctor, and in cases of extreme distress would call 911 immediately. LVN O said she was familiar with the Nurse Proficiency Audit. LVN O said the Nurse Proficiency Audit was completed on hire and annually. She said skills are observed and guidance given as needed. During an interview with the DON on [DATE] at 12:35 p.m., she said Resident #1 was transferred to the hospital on [DATE] at 10:05 a.m. She said all in-services related to the incident were completed at an unspecified time on [DATE]. Three other residents (Resident's #s 3, 4, & 5) who had experienced recent changes of condition were reviewed for physician notification and indicated all three received timely assessment and intervention, including physician notification and transfer to the hospital.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice and based on the comprehensive assessment, were provided for 1 of 4 residents reviewed for pressure ulcers. (Resident #102) The facility did not provide pressure relief for Resident #102 after she developed a facility acquired stage 2 pressure ulcer on her coccyx area. The resident would sit for long periods of time in her wheelchair without being repositioned off of her wound. The pressure ulcer worsened to an unstageable and required debridement revealing a stage 4 pressure ulcer with ligaments visible. This failure could place 20 residents who were identified as a moderate or high risk for developing pressure ulcers at risk for the development of new pressure ulcers and the worsening of existing pressure ulcers. Findings included: Physician orders [REDACTED].#102, admitted [DATE], was an [AGE] year old female with [DIAGNOSES REDACTED]. A weekly ulcer assessment dated [DATE] indicated Resident #102 had a new stage 2 pressure ulcer on her coccyx area measuring 2.6 cm x 2.0 cm x 0.1 cm. A Braden Scale assessment dated [DATE] indicated Resident #102 was a moderate risk for the development of pressure ulcers. The most recent MDS dated [DATE] indicated Resident #102 had severe cognitive impairment and required extensive assistance of two staff to transfer, dress, and toilet. The assessment indicated Resident #102 used a wheelchair for mobility and was always incontinent of bladder and bowel. The assessment indicated Resident #102 had a stage 4 pressure ulcer, not present on admission, measuring 4 cm x 3.5 cm with slough. A nursing progress note dated 6/18/17 indicated PA B was notified of a foul odor when changing the dressing on Resident #102's coccyx area. A laboratory panel report for Resident #102, collected 6/19/17 at 4:16 a.m., indicated a low pre-[MEDICATION NAME] level of 3.7mg/dl (reference range 17-34 mg/dl), and severe protein depletion. A weekly ulcer assessment dated [DATE] indicated Resident #102's coccyx area pressure ulcer was now unstageable measuring 4.0 cm x 3.5 cm and unable to determine depth. The assessment indicated the wound bed was yellow and black with eschar present and the amount of necrosis was 100%. There was moderate amounts of yellowish drainage and a foul odor. During an interview on 7/5/17 at 12:10 p.m., LVN A said Resident #102 developed a facility acquired pressure ulcer on her coccyx area on 6/16/17 and the DON classified it as a stage 2. LVN A said on Monday (6/19/17), Resident #102's coccyx area pressure ulcer had a foul odor and the wound bed was not visible due to the presence of slough and eschar; the DON classified it as unstageable. LVN A said Physician D saw Resident #102 on 6/23/17 and debrided the coccyx area pressure ulcer. She said Physician D classified it as a stage 4 after debridement because ligaments were visible. LVN A said repositioning and turning was uncomfortable for the resident. LVN A said frequently when she saw Resident #102 she was already up in the wheelchair or already in therapy. LVN A said once the resident's wound was unstageable, she asked therapy staff to lay the resident down after the therapy session. She said she did not remember who she spoke to in the therapy department. A weekly ulcer assessment dated [DATE] for Resident #102 was completed following debridement by Physician D (on 6/23/17). The assessment indicated after debridement the wound measured 4.0 cm x 3.5 cm x 3.0 cm depth and was a stage 4. The assessment indicated undermining around the entire wound bed and yellow slough covering 100% of the wound bed. A care plan dated 7/4/17 indicated Resident #102 had a potential for pressure ulcer development as well as an existing stage 4 pressure ulcer on her coccyx area. Interventions included: educate caregivers as to causes of skin breakdown, including transfer/positioning requirements and frequent repositioning, follow facility policies and protocols for the prevention/treatment of [REDACTED]. During an observation on 7/4/17 at 11:15 a.m., Resident #102 was not in the facility. She was at an in-patient hospice. She was lying in bed and had no response to verbal stimuli. A turn/repositioning report, printed 7/5/17, indicated Resident #102 was not turned or repositioned on: *6/1/17 during the 10p-6a shift *6/6/17 during the 6a-2p shift *6/7/17 during the 6a-2p shift, *6/7/17 during the 2p-10p shift *6/7/17 during the 10p-6a shift *6/9/17 during the 6a-2p shift *6/14/17 during the 6a-2p shift, and *6/15/17 during the 6a-2p shift. During an interview on 7/5/17 at 1:43 p.m., LVN H said she provided care for Resident #102. LVN H said she was not aware of any instance where Resident #102 refused to be turned. During an interview on 7/4/17 at 2:41 p.m., the RD said she saw Resident #102's pressure ulcer on 6/26/17 for the first time. The RD said she was not aware Resident #102 had any kind of wound at all until that point. The RD said if she had known about Resident #102's stage 4 pressure ulcer, the therapy department probably would have worked on repositioning techniques. During an interview on 7/6/17 at 2:57 p.m., Therapist F said sometimes Resident #102 would be up in her wheelchair waiting in the morning to go to therapy. Therapist F said the therapist would take Resident #102 back to her room and let nursing know she was back. Therapist F said the times she took Resident #102 back to her room, she would want to stay up in the wheelchair. She said the resident often told her that she did not like to stay in the bed. Therapist F said she was not aware of Resident #102's pressure ulcer until she read the nursing notes about a dressing change. Therapist F said there was no change in Resident #102's therapy routine related to the pressure ulcer and the RD told them there were no special precautions related to the pressure ulcer. During an interview on 7/6/17 at 2:08 p.m., CNA J said Resident #102 was usually in the wheelchair in the mornings and she would eat breakfast sitting up. CNA J said Resident #102 would stay in the wheelchair and wait for therapy after breakfast. CNA J said after therapy, they brought Resident #102 back to her room. CNA J said if Resident #102 needed incontinent care, they would transfer her back to the bed for care, then back into the wheelchair for lunch time. CNA J said after lunch sometimes Resident #102 would go back to bed, but sometimes she wanted to stay up in the wheelchair. CNA J said at times Resident #102 would still be up in the wheelchair at 2:00 p.m. when her shift was over. During an interview on 7/5/17 at 1:55 p.m., RN I said she was assigned to care for Resident #102 on the 6a-2p shift. She said Resident #102 was usually up in her wheelchair for therapy when she started her shift. RN I said Resident #102 after a couple hours in therapy, the resident would sit up in her wheelchair to eat lunch. During an interview on 7/5/17 at 2:08 p.m., CNA K said she had cared for Resident #102. CNA K said the therapy department would often have Resident #102 up in her wheelchair in the morning and would bring her back before lunch. CNA K said she had never transferred Resident #102. During an interview on 7/5/17 at 2:17 p.m., CNA J said she was assigned to care for Resident #102. CNA J said Resident #102 complained of pain when she was in the wheelchair. CNA J said sometimes Resident #102 did not want to be repositioned. During an interview on 7/5/17 at 3:54 p.m., CNA M said she was assigned to provide care for Resident #102. CNA M said Resident #102 liked to lay with the head of her bed up and flat on her back like in a sitting position. During an interview on 7/5/17 at 4:01 p.m., CNA N said she was assigned to provide care for Resident #102. CNA N said Resident #102 liked to have the head of the bed elevated while she was in bed an to lie on her back. During an interview on 7/6/17 at 2:25 p.m., CNA O said she was assigned to provide care for Resident #102. CNA O said Resident #102 was usually up in her wheelchair during the day for therapy. During an interview on 7/6/17 at 2:29 p.m., CNA P said she was assigned to provide care for Resident #102 on the 6a-2p shift. CNA P said usually the CNAs would transfer the resident to the wheelchair to wait for therapy. CNA P said sometimes staff would put her back in bed after lunch. During an interview on 7/7/16 at 11:01 p.m. CNA Q said Resident #102's daily routine on the morning shift would be to get her up in the wheelchair and wait for therapy to come get her. CNA Q said the routine was to transfer Resident #102 to her wheelchair in the morning and therapy would come get her for 2-3 hours and bring her back around lunch time. CNA Q said Resident #102 ate lunch in her room sitting in the wheelchair. During an interview on 7/6/17 at 3:51 p.m., the ADON said Resident #102 would be up in her wheelchair in the morning for therapy and after a couple hours in therapy, she would come back before lunch. The ADON said Resident #102 would sit up in her wheelchair to eat lunch. During a telephone interview on 7/6/17 at 12:37 p.m., Physician D said he saw Resident #102 once, the day he debrided her pressure ulcer. Physician D said Resident #102 should be in the wheelchair no more than 2 hours before offloading and that if she were left in the wheelchair too long that is bad. During an interview on 7/4/17 at 4:09 p.m., the DON said on 6/16/17 LVN G identified a stage 2 pressure ulcer on Resident #102's coccyx area during the weekly skin assessment. She said this was the first time a pressure ulcer was identified for the resident. The DON said on 6/19/17 the wound was unstageable due to the presence of yellow slough. The DON said on 6/23/17 the wound had not improved and Physician D treated the pressure ulcer with debridement. She said Resident #102 was placed her on hospice service the next day, 6/27/17. A facility policy of wounds care, revised March 7, 2007, indicated residents at risk for pressure ulcer development should be repositioned at least every two hours. The policy indicated any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned at least every hour or be put back to bed. The treatment nurse and the DON should add a written plan for the use of positioning devices and schedules to the care plan. The policy indicated the presence of a pressure reducing device did not negate the need to turn/reposition at least every two hours. According to the website, http://www.npuap.org/resources/educational-and-clinical-resources, accessed 7/18/17, it indicated: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel . Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. A Braden Scale report dated 7/4/17 indicated 20 residents in the facility were considered at moderate or high risk for developing a pressure ulcer.

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development and worsening of pressure sores for 2 of 5 residents reviewed for pressure sores. (Resident #s 27 and 50) 1. Resident #27 was admitted without pressure sores and was at low risk for the development of pressure sores. The resident developed a facility-acquired pressure sore that was not identified until it was unstageable. The facility did not evaluate or provide the resident with repositioning or pressure relief. 2. Resident #50 was admitted without pressure sores, but was at high risk for the development of pressure sores. She developed a facility-acquired stage III pressure sore that was not identified by staff until it was a stage III pressure sore. The facility did not evaluate or provide the resident with repositioning or pressure relief. These failures contributed to the development of new pressure sores for Resident #s 27 and 50. This failure could place 9 residents with pressure sores at risk for the development of new pressure sores and decline in existing pressure sores. Findings included: 1. Physician orders [REDACTED].#27 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated she was on hospice for [MEDICAL CONDITION]. The most recent MDS dated [DATE] indicated Resident #27 had severely impaired cognition, had extensive dependence for ADLs including bed mobility, was totally bowel and bladder incontinent, and had no pressure sores. A care plan initiated 02/21/14 indicated Resident #27 had the potential for pressure sore development related to poor mobility, poor nutritional intake at times, and bowel/bladder incontinence. Interventions included monitor for changes in skin status. There were no interventions for pressure-relieving devices. The care plan was updated 04/01/15 and indicated Resident #27 had a pressure sore to the "Right lateral ankle see current treatment orders." There were no new interventions. Resident #27 had no palliative care plans indicating the development of pressure sores was unavoidable. A Braden scale for predicting pressure sore risk dated 03/31/15 indicated Resident #27 was at low risk for pressure sore development. A weekly skin assessment for Resident #27 dated 04/01/15 indicated an abrasion to the right lateral ankle measuring 0.4 cm (centimeters) x 0.4. cm x 2.5 cm with redness. A telephone order for Resident #27 dated 04/01/15 indicated to apply skin prep to right lateral ankle daily.'' A weekly skin assessment for Resident #27 dated 04/08/15 indicated an abrasion to the right lateral ankle measuring 0.4 cm x 0.4 cm x 2.5 cm. The treatment nurse documented, "Resident had an abrasion to the right ankle that is now open with light drainage." She indicated the hospice nurse assessed the site and received orders for a wound care physician to assess the wound. A telephone order for Resident #27 dated 04/08/15 indicated a wound care physician was to assess the wound. A wound care assessment for Resident #27 from the wound care physician dated 04/09/15 indicated the wound was covered with adherent yellow slough (necrotic tissue.) The physician debrided the wound with a blade and the pressure sore was a stage III measuring 0.3 cm x 0.3 cm x 0.3 cm. He changed the treatment to cleanse with normal saline, apply collagen, and cover with a bordered foam dressing. A weekly ulcer assessment for Resident #27 dated 04/09/15 indicated the same information as the physician wound care assessment dated [DATE]. The assessment also indicated pressure reducing devices in place were pillows to float heels. There were no other pressure reducing devices documented. A wound care assessment for Resident #27 from the wound care physician dated 04/16/15 indicated the wound was unchanged, stage III 0.3 cm x 0.3 cm x 0.2 cm with maceration (soft, white from wetness) to surrounding skin. Biofilm (thin layer of microorganisms) was debrided. He changed the treatment to cleanse with normal saline, apply alginate, and cover with a dressing. A weekly ulcer assessment for Resident #27 dated 04/16/15 indicated the same information as the physician wound care assessment dated [DATE]. The assessment also indicated pressure reducing devices in place were pillows to float heels. There were no other pressure reducing devices documented. A wound care assessment for Resident #27 from the wound care physician dated 04/23/15 indicated the wound was stage III measuring 0.2 cm x 0.2 cm x 0.2 cm with granulation tissue. He changed the treatment to cleanse with normal saline, apply collagen, and cover with a dressing. A weekly ulcer assessment for Resident #27 dated 04/23/15 indicated the same information as the physician wound care assessment dated [DATE]. The assessment also indicated pressure reducing devices in place were pillows to float heels. There were no other pressure reducing devices documented. A wound care assessment for Resident #27 from the wound care physician dated 04/30/15 indicated the wound was stage III measuring 0.1 cm x 0.1 cm x 0.1 cm and covered with yellow slough. The physician debrided the wound and post-debridement measurements were 0.1 cm x 0.1 cm x 0.2 cm. He did not change the treatment order. A weekly ulcer assessment for Resident #27 dated 04/30/15 indicated the same information as the physician wound care assessment dated [DATE], pre-debridement measurements. The assessment also indicated pressure reducing devices in place were pillows to float heels. There were no other pressure reducing devices documented. A wound care assessment for Resident #27 from the wound care physician dated 05/07/15 indicated the wound was stage III measuring 0.2 cm x 0.2 cm x 0.0 cm. His assessment notes indicated, "100% scab." He changed the order to apply skin prep daily. A weekly ulcer assessment for Resident #27 indicated the same information as the physician wound care assessment dated [DATE]. The assessment also indicated pressure reducing devices in place were pillows to float heels and wheelchair cushion. There were no other pressure reducing devices documented. During an observation and interview on 05/12/15 at 10:20 a.m., the treatment nurse indicated Resident #27's wound started as an abrasion, then had blanchable redness which later began leaking "fluid", so a wound care physician was consulted and he diagnosed the wound as a pressure sore. She stated it had "now closed back up to necrotic tissue." Resident #27 was lying to the right with her right lateral ankle against the mattress. There were no pillows or other pressure-reducing devices to remove pressure from the right lateral ankle. The mattress was not a low air loss mattress. The treatment nurse measured the pressure sore: 0.2 cm x 0.2 cm with a hard, brown area in the center. The surrounding tissue was inflamed. Resident #27 said her ankle was sore and hurt when touched. The treatment nurse said the wound care physician had not changed the staging. The treatment nurse left the room. Resident #27 was lying to the right with her right ankle rotated outward against the mattress. There were no pillows or other pressure relieving devices. During observations on 05/11/15 at 9:28 a.m. and 2:27 p.m., Resident #27 was lying in bed. Her right ankle was rotated outward against the mattress. Resident #27 had no pillows or other pressure relieving devices to the right outer ankle. During the following observations on 05/12/15, at 10:10 a.m., 10:20 a.m.,11:33 a.m.,12:18 p.m.,12:36 p.m. and 4:37 p.m., Resident #27 was lying in bed. Her right ankle was rotated outward against the mattress. Resident #27 had no pillows or other pressure relieving devices to the right outer ankle. During the following observations on 05/13/15, at 10:10 a.m., and 12:35 p.m., Resident #27 was lying in bed. Her right ankle was rotated outward against the mattress. Resident #27 had no pillows or other pressure relieving devices to the right outer ankle. During an interview on 05/12/15 at 5:05 p.m., the DON said she was aware of Resident #27's pressure sore. She said on 05/07/15, the wound care physician documented Resident #27's pressure sore as a stage III. She indicated she would have called the pressure sore unstageable since the wound bed was not visible. The DON said she was not aware pillows or other pressure relieving devices were not being used per the weekly skin assessment interventions. During an interview on 05/14/15 at 4:00 p.m., the treatment nurse said she did not have pressure sore care plans with the treatment orders. She said she was going to be trained on doing those care plans, but had not started. During an interview on 05/15/15 at 2:42 p.m., the wound care physician said he first saw Resident #27's wound on 04/09/15 and "it was unstageable." He said he had to debride the wound because it was covered with yellow slough. The wound care physician said when the slough was removed, Resident #27's pressure sore was a stage III. He said he continued to monitor the pressure sore weekly. The wound care physician said on 04/30/15, Resident #27's pressure sore had worsened to unstageable and was covered with yellow slough. He said after [MEDICATION NAME] the wound, it was a stage III. He said after assessing the pressure sore today (05/15/15), he would continue treatment with skin prep. 2. Physician orders [REDACTED].#50 was [AGE] years old, readmitted [DATE] with [DIAGNOSES REDACTED]. Change respiratory tubing every Monday night. A Braden scale dated 04/11/15 indicated Resident #50 was a high risk for pressure sores. A care plan initiated on 01/27/15 indicated Resident #50 had potential for pressure sores. The most recent MDS dated [DATE] indicated Resident #50 had severely impaired cognition and required extensive dependence for bed mobility. A weekly skin assessment for Resident #50 dated 05/04/15 indicated she had a fading bruise to the right forearm, a scab to the right hand, and excoriation to the left upper buttock. According to this form, Resident #50 did not have any pressure sores. During an interview on 05/11/15 at 2:44 p.m., the treatment nurse said she discovered Resident #50 had a pressure sore behind her right ear from the nasal cannula tubing. The treatment nurse identified the pressure sore on 05/11/15. She said the oxygen tubing was changed once a week. The treatment nurse said when the tubing was changed they did not put the padding behind her ears. The treatment nurse said she noticed last week the back of the right ear was irritated. During observation and interview on 05/11/15 at 3:50 p.m., Resident #50 was lying in bed with nasal cannula tubing behind her ears. The tubing was not padded. Resident #50 had a pressure sore behind her right ear. The treatment nurse measured the pressure sore at 0.5 cm x 0.3 cm. The wound was open with no drainage or odor. The treatment nurse assessed the pressure sore as a stage III, but said she was "not good at staging" pressure sores. During an interview on 05/12/15 at 5:00 p.m., the DON said they did not place the foam ear padding on the nasal cannula tubing after they changed it. The DON then said the treatment nurse needed more training. The May 2015 TAR indicated Resident #50 was to have, "...Ear padding for continuous oxygen via nasal cannula q (every) shift..." The TAR was initialed on each shift from 05/01/15 to 05/11/15. The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 05/15/15 indicated the following: "Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable." "Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body's natural (biological) cover " and should not be removed." A Pressure Ulcer: Prevention, Assessment, and Treatment policy and procedure dated 2003 indicated the following: "A standardized treatment protocol provides consistency of care, prevents tissue breakdown, stimulates circulation to areas of potential breakdown, reduces infection and promotes healing." "Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of [REDACTED]. 4. Causes of Pressure Ulcers: 1. Unrelieved pressure over a bony prominence resulting in ischemia at the area of pressure..." 6. Nursing Action/Rationale: Prevention: The nurse can assist in the prevention of pressure ulcers by performing the following nursing interventions: NOTE: Add any interventions to care plan...5. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure...10. Assess for early signs of skin breakdown and report abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin..." "2. Pressure sore identification...Note: If wound involves necrotic tissue, staging cannot be confirmed until wound base is visible. Therefore these wounds would be unstageable. Staging definitions are per the guidelines of the National Ulcer Advisory Panel February 2007 definitions..." "Stage IIIFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable." "Unstageable: Full thickness skin or tissue lossFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed." The CMS 672 dated 05/11/15 indicated 9 residents had pressure sores. Surveyor: SMITH, BECKY