Every finding on record at Chelsea Gardens

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 6 (Resident # 1 and Resident #2 ) rooms reviewed for environment. The facility failed to ensure Resident # 1 and Resident # 2 rooms were free of odor. The facility failed to ensure the hallway to the conference room and the conference room were free of musty odor This failure could place residents, staff and visitors at risk of infection and illness. Findings included: Observation of the facility hallway leading to the conference room and the conference room on 06/10/2026 at 07: 48 a.m., smelled musty and moldlike. In an interview on 06/10/2026 at 09:04 a.m., with CNA A, she said there was a room that had an odor, room [ROOM NUMBER]. She said the resident who was in room [ROOM NUMBER] was moved to room [ROOM NUMBER] by maintenance staff and the resident's family member. CNA A said Resident # 2 and his family did not like the musty odor of the carpet. In an interview on 06/10/2026 at 09:20 a.m., with Resident # 1, she said she did not request a room change from 115 to room [ROOM NUMBER]. She said she was happy the facility moved her to a new room because the carpet smelled like urine and feces. Resident # 1 said the smell from the carpet made her feel she was not welcomed. She said the odor was disgusting. She said with the odor she felt like an animal. In an interview with Resident # 2's family member at bedside on 06/10/2026 at 1;13 p.m., she said they requested a room change because the carpet did not smell good. She said Resident # 2 told her he did not like the odor of the carpet. Resident # 2's family member said, she was concerned about the effect the carpet odor could have on Resident # 2's health. In an interview with Housekeeper A on 06/10/2026 at 2:56 p.m., he said it was the responsibility of the housekeeping staff to make sure the rooms were cleaned and free of awful odor. He said if there was a spot on the floor, housekeeping staff would clean it. He said if there were no spots, housekeeping staff would vacuum the carpet. He said sometimes there were spills on the carpet or water from the bathroom drains. He said the last room he noticed smelled like urine was room [ROOM NUMBER]. He said room [ROOM NUMBER] was cleaned and disinfected but since the last resident was removed there had being no new resident in that room. In an interview with RN A on 06/10/2026 at 3:08 p.m., he said it was the responsibility of the housekeepers to care for the carpets. He said if a room with a carpet had an odor it would affect the residents' health negatively. He said it could affect residents with respiratory issues negatively because their breathing and lungs might be affected. In an interview with RN B on 06/10/2026 at 3:10 p.m., she said the musty odor rooms with carpets could affect Resident#1 and Resident # 2 's health and the staff would not know what the residents had inhaled. She said some residents residing at the facility had respiratory issues and that might affect their breathing. She said if she noticed a room with carpet had an odor, she would have notified her supervisor so the resident would be moved to another room. RN B said she noticed Resident # 2 was moved to another room because he complained of the odor on the carpet. In an interview with the Housekeeping Supervisor on 06/10/2026nat 3:20 p.m., he said it was the responsibility of the Housekeepers to make sure the rooms were cleaned. He said if the residents or staff notified him of any problems with the carpets, he would address it. He said if the carpet smelled like urine or feces, he would use cleaning chemicals designed for carpets, such as -Premium carpet shampoo to clean the carpet. The Housekeeping Manger said before a new resident was admitted into a room, he went into the room and made sure the carpet smelled fresh. He said he was not aware some rooms had an odor from the carpet because he was not notified. In an interview with the DON on 06/10/2026 at 3:36 p.m., he said when he realized a room floor covered with carpet did not smell good, he would notify the ADM, who would reach out to maintenance to clean the carpet. He said staff told him Resident # 2 was moved to another room because the family requested a room change because the carpet in his previous room did not smell good. The DON said a room with a carpet that had an odor could affect the health of a resident negatively because if they had respiratory illnesses, it would affect their breathing. In an interview with the ADM on 06/10/2026 at 3:50 p.m., he stated room [ROOM NUMBER] had an odor. He said the Housekeeping Supervisor cleaned the carpet. He said the carpet with an odor could affect residents' breathing. The ADM said the facility had started changing the room floors from carpet to wood and waterproof floors. He said the first hallway had been changed with the exception of room [ROOM NUMBER]. Record review of facility's document titled: Environment Services Cleaning Procedure for Common Items, dated 2025, referenced from: Centers for Disease Control and Prevention Guidelines for Environmental Infection Control in Healthcare Facilities (2003): Recommendations of the Healthcare Infection Control Practices Advisory Committee revealed: Floor. Cleaned on a regular basis when soiled, between residents and after discharge. Carpet. Vacuum and shampoo according to cleaning schedule and as necessary. Carpet should be vacuumed on a regular basis. Carpeting that remained damp should be removed ideally with 72 hours. Record review of the facility's policy titled: Safe and Homelike Environment, dated 2025, stated: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #1) reviewed for care plans.The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address meet Resident #1's medical, nursing, and mental and psychosocial needs related to his history of choking on food while eating and requirement for mechanical altered diet.The facility also failed to implement Resident #1's care plan intervention of assistance with eating and monitoring for signs of dysphagia on 2/28/2026 evidenced by Resident #1 being left alone to eat a sandwich which resulted in Resident #1 being found by CNA A unresponsive in his room with the sandwich in his hand and food leaking from his mouth.EMS had to clear Resident #1's airway by suctioning emesis (vomit) from his airway and vocal cords, initiate CPR and intubate him. Life saving measures were continued for Resident #1 as he was transported to the hospital and was pronounced deceased .An Immediate Jeopardy (IJ) was identified on 3/6/2026. The IJ template was provided to the facility on 3/6/2026 at 7:15 pm. While the IJ was removed on 3/9/2026, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.This failure could place residents who require supervision and assistance with meals at risk for experiencing hospitalization, choking and/or death.Findings included:Record review of Resident #1's face sheet dated 3/5/2026 revealed he was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted on [DATE], and discharged to an Acute Care hospital on 3/1/2026. Diagnoses included End-Stage Renal Disease (final, permanent stage of chronic kidney disease, where kidneys can no longer function on their own), acquired absence of the right leg (post-traumatic or surgical loss of the limb of the right leg), acquired absence of the left leg (post-traumatic or surgical loss of the limb of the left leg), Type II diabetes mellitus (chronic high blood glucose from insulin resistance and relative insulin deficiency), dysphagia (difficulty swallowing), fatigue (overwhelming physical or mental exhaustion-that does not improve with rest), muscle weakness (a reduced capacity to exert force with muscles), reduced mobility (decline in the ability to move independently), need for assistance with personal care (essential assistance for seniors and individuals with disabilities), and dependence on renal dialysis (long-term reliance on hemodialysis or peritoneal dialysis to replace failed kidney function).Record review of Resident #1's undated dashboard page in the electronic record revealed special instructions stating, .ASSIST RESIDENT IN EATING DUE TO UNABLE TO SEE.Record review of Resident #1's Care Plan revised on 3/27/2024 revealed a focus area for potential nutritional problems (weight gain/loss) related to weakness, diabetes mellitus, dysphagia, and impaired cognition (noticeable declines in memory, language, thinking, and judgment). Interventions included monitoring, documenting, and reporting as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, multiple swallowing attempts, refusing to eat, and appearing concerned during meals. Further review of care plan did not note a focus section referencing dysphagia diagnosis, previous choking history or RP concern for monitoring Resident when being fed.Record review of Resident #1's progress note dated 11/28/2024 at 9:46 AM noted the resident was coughing and possibly choking while being assisted with breakfast. It was further noted that upon assessment, resident was coughing and continued to spit up particles of food. The progress note indicated the NP was informed and ordered Zofran as needed for nausea and vomiting, as well as a diet change to mechanical soft and a Speech Evaluation.Record review of Resident #1's progress note dated 11/30/2024 at 1:47 PM noted, With regard to the incident of the resident choking on food, family is requesting the resident be supervised during meals at all times.Record review of Resident #1's progress note dated 12/1/2024 at 7:01 PM by SLP noted two attempts were made to assess the resident's swallowing skills; however, the resident refused lunch, and when the SLP attempted to observe dinner, the resident had already eaten. The SLP documented that nursing staff informed her the diet had been changed to mechanical soft by the NP, and the NP requested the resident be monitored during meals for safety.Record review of Resident #1's physician order initiated on 5/12/2025 revealed an order for a regular diet with mechanical soft texture and thin/regular consistency.Record review of Resident #1's Care Plan revised on 5/19/2025 revealed a focus area for ADL self-care performance deficit related to activity intolerance, confusion, limited mobility, left above-knee amputation, right below-knee amputation, ESRD, and impaired range of motion in bilateral upper extremities. Interventions revised on 8/20/2025 indicated the resident required partial/moderate staff assistance with eating.Record review of Resident #1's Speech Screening dated 6/12/2025 revealed he was screened after readmission from the hospital and was not recommended for speech therapy services because the assessment indicated he was at his previous baseline with no changes. The screening documented he tolerated his prescribed diet of regular texture with chopped meat. The screening further noted Resident #1, .continues to present similar oral dysphagia with regular texture without chopped meat due to prolonged chewing, reduced bolus formation, and delayed oral transit time. Chopped meat facilitates reduced time for the patient to manipulate food prior to swallowing.Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7/15, indicating severely impaired cognition.Further review of the MDS revealed:Adequate visionLimited range of motion in both upper extremitiesRequired partial/moderate assistance with eating The MDS also indicated Resident #1 was:Dependent for sit-to-lying, lying-to-sitting, and chair/bed transfersRequired substantial/maximum assistance to roll left and rightUnable to sit-to-stand or walk 10 feetFurther review indicated the resident was on a mechanically altered and therapeutic diet.Record review of Resident #1's progress note dated 12/18/2025 at 2:06 PM by the Registered Dietitian (RD) revealed the resident's diet remained regular diet, mechanical soft texture, thin/regular consistency, and he continued to require assistance with meal setup and feeding at lunch and dinner due to fatigue. The RD recommended assisting Resident #1 with meal setup and feeding during lunch and dinner.Record review of Resident #1's dietary profile assessment dated [DATE] revealed the resident's diet order remained regular diet, mechanical soft texture with thin liquids, and he required partial assistance with eating.Record review of Resident #1's Care Plan Meeting Summary dated 2/5/2026 revealed RP voiced concern about Resident #1's appetite and her ordering food for him but he is not being fed. Summary further noted that RP was told CNA's will attempt to feed resident, but he refuses to eat.Record review of Resident #1' progress note dated 2/28/2026 at 11:35am by LVN A noted, At about 23:30 (11:30PM), nurse was called from a room where she is attending to 911 situation with 911 dispatcher crew that resident is unresponsive. Nurse assessed resident no breathing, pulse, nurse Call for help and initiate CPR. The 911 dispatcher team that was in the other room came and took over from the nurse. Resident RP and spouse came while 911 team was working on resident. Another 911 call made for the other resident. 911 crew worked on the resident and pulse felt and was transported to hospital at 12:33am. Notification to NP, DON.Record review of Resident #1's progress note dated 2/28/2026 at 11:20pm by LVN A notes, Nurse checked on resident, at the beginning of the shift no discomfort observed. At approximately past 10 PM writer was informed by another staff that resident RP needs to speak with the nurse. Nurse called RP and she asked how resident is doing and that she would like to speak to resident if he needs something to eat so she can order for delivery. Nurse asked the RP to hang up to enable nurse dial RP from resident room. Nurse went to resident room called RP from resident room and put the phone on speaker per resident request and nurse did. RP asked if she should order food for resident. Resident said no that he is okay. Nurse informed RP that the kitchen manager is in the building and met with resident and she is preparing food for resident. RP then said she will visit resident tomorrow. Nurse then asked assigned aide to assist resident with meal when the kitchen manager brings it to resident.Record review of EMS report for Resident #1 dated 3/1/2026 revealed upon assessment at 11:41pm Resident #1's airway was completely obstructed, his pulse and breathing were absent, and he was unresponsive. Also, upon assessment he had fluid loss of 100 - 500ml of emesis. Resident #1's primary impression was noted to be cardiac arrest. EMS report detailed Resident #1 went into cardiac arrest prior to EMS arrival and the arrest was not witnessed, CPR initiated on 2/28/2026 at 11:40pm. Resident #1's first monitored rhythm was Ventricular Fibrillation (a life-threatening heart rhythm emergency where the heart's lower chambers quiver chaotically instead of pumping blood, resulting in sudden cardiac arrest and loss of pulse. It requires immediate CPR and defibrillation (shock) to restore a normal rhythm). Cardiac arrest report further detailed EMS first initiated CPR and use of AED. According to the narrative in the EMS report they were in the facility responding to a call regarding another resident when a staff member entered the room and stated another resident at the facility (Resident #1) was found choking in his room. Resident #1 was found supine on the floor unresponsive, apneic (not breathing), and pulseless. The narrative detailed, .no obvious external injuries or bleeding observed upon visual inspection. Patient is unresponsive. Airway completely obstructed by emesis. hands only CPR was initiated. Oral suctioning performed and I-gel (supraglottic airway device designed for rapid, blind insertion to manage airways during resuscitation) was placed with manual ventilations via BVM initiated. Due to excessive vomiting, the I-gel removed and suctioning was continued. intubation was performed and successful. initial rhythm interpreted as asystole. Staff on scene stated they last spoke with Resident #1 approximately 30 minutes before finding him unresponsive. The narrative went on to detail interventions attempted with Resident #1 to stabilize him, it was noted he was eventually transported to the hospital while EMS continued lifesaving interventions. It was noted at arrival to the hospital CPR continued by hospital staff, but he was declared deceased .Record review of Resident #1's progress note dated 3/1/2026 at 1:24am by LVN A revealed Hospital called to report Resident #1 had passed away in the hospital.Record review of Resident #1 hospital record dated 3/1/26 revealed he arrived to the hospital with CPR in progress via EMS and he was last seen at baseline around 11:15pm. RP was present and voiced she was notified by facility staff Resident #1 was found unresponsive and may have been choking prior to the event. Hospital records detailed CPR was continued at hospital but Resident #1 was pronounced deceased at 1:16AM.Observation on 3/4/2026 at 1:16pm, Business Office Manager (BOM) displayed facility's video footage from 2/28/2026, review of video footage revealed approximately at:10:54pm LVN A was on the phone at the nurse's station10:59pm LVN A entered Resident #1's room11:04pm LVN A came out of Resident #1's room11:05pm Dietary Manager went into Resident #1's room carrying a meal tray11:07pm Dietary Manager came out of Resident #1's room and went down the hall11:21pm LVN A went down another hall with nurse cart11:31pm CNA A went into Resident #1's room11:32pm CNA A came out of Resident #1's room waving for help and then reentered Resident #1's room11:32pm RN A went to Resident #1's room11:33pm LVN A came back down the hall and into Resident #1's room11:34pm CNA A came out of Resident #1's room and ran down the hall, she returned a few seconds later with EMS staff and they entered Resident #1's room at 11:35pm.Summary of the video footage included Resident #1 was brought a meal tray by Dietary Manager, Dietary Manager left the room and there was no clear footage of anyone else entering Resident #1's room again until CNA A entered approximately 24 minutes later.Interview on 3/4/2026 at 3:31 PM, the Dietary Manager stated she was at the facility on the night of 2/28/2026 conducting an in-service with nurses and CNAs regarding customer service and diet textures. The Dietary Manager stated she answered a call at the nurse's station around 11:00 PM from Resident #1's Responsible Party (RP), who was upset because Resident #1 had gone to dialysis earlier that day and had not eaten since returning to the facility. The Dietary Manager stated she told the RP she would ensure Resident #1 received food. The Dietary Manager stated she went to Resident #1's room and observed two untouched meal trays. She asked Resident #1 if he was hungry, and he responded yes and requested a turkey sandwich with cheese and mayonnaise. The Dietary Manager stated she removed the old trays and went to retrieve a sandwich for Resident #1. The Dietary Manager stated that while leaving the room to obtain the sandwich, she saw Resident #1's CNA (CNA A) and informed her that she was bringing Resident #1 a meal tray and that he would require assistance with eating. The Dietary Manager stated she returned to Resident #1's room with the requested sandwich and a banana from the earlier tray. The Dietary Manager stated she placed the tray on the bedside table near the door, which was not within the resident's reach. The Dietary Manager stated Resident #1 requested a soda with his meal, and she told him she would retrieve one and that the CNA would be in shortly to assist him with eating.The Dietary Manager stated that as she walked down the hall to get the soda, she heard a resident in the 100 hall calling for help. She stated the resident calling for help was her mother (Resident #2). The Dietary Manager stated she immediately went to the room to check on her mother, who was complaining of chest pain, and she alerted a nurse for assistance. The Dietary Manager stated she remained with Resident #2 while she was being assessed, and 911 was called. The Dietary Manager stated she remained at her mother's bedside until EMS arrived at approximately 11:15 PM. The Dietary Manager stated that while EMS was stabilizing her mother, CMA B entered the room and asked if one of the paramedics could come with her because Resident #1 had been found unresponsive when CNA went to feed him. The Dietary Manager stated one paramedic left the room with the CNA to check on Resident #1, while the remaining paramedic later wheeled Resident #2 down the hall to Resident #1's room so he could also assist. The Dietary Manager stated additional paramedics later arrived and transported Resident #2 to the hospital, while the original EMS crew remained with Resident #1. The Dietary Manager stated that to her knowledge, Resident #1 required assistance with eating due to vision impairment, but she believed he was able to eat finger foods independently. The Dietary Manager stated she was not aware of Resident #1 having a history of choking on food.Interview on 3/4/2026 at 3:59 PM, LVN A stated she worked the 6:00 PM-6:00 AM shift on 2/28/2026, and Resident #1 was assigned to her. LVN A stated Resident #1 had gone to dialysis earlier that day, and when he returned he was tired and did not want to eat. LVN A stated that later that night she was informed by the Dietary Manager that she needed to call Resident #1's Responsible Party (RP). LVN A stated she immediately called the RP, who requested to speak with Resident #1. LVN A stated she hung up the phone and then called the RP again from Resident #1's room, allowing them to speak on speakerphone at the resident's request. LVN A stated the RP asked Resident #1 if he wanted her to have food delivered, and Resident #1 said no. LVN A stated she reassured the RP that the Dietary Manager was bringing Resident #1 something to eat. LVN A stated that after Resident #1 finished speaking with the RP, she hung up the phone and left the room. LVN A stated she informed CNA A that the Dietary Manager was bringing food for Resident #1 and that CNA A would need to assist him with eating. LVN A stated that shortly afterward, a resident across the hall required assistance, and she, CNA A, and CMA B went into that resident's room to provide care for approximately 10 minutes. LVN A stated that when she left the room across the hall, she looked into Resident #1's room and did not observe a meal tray in the room at that time. LVN A stated she continued down the hall when RN A approached her regarding Resident #2 experiencing chest pain, and she went to assist in Resident #2's room.LVN A stated she remained in Resident #2's room assisting until EMS arrived. LVN A stated that while she was giving report to EMS, she heard her name being called and went into the hallway where staff directed her to Resident #1's room. LVN A stated she entered Resident #1's room and observed the resident to be unresponsive with no pulse. LVN A stated she performed a mouth sweep, but nothing was removed. LVN A stated she and the CNAs placed a backboard under Resident #1, lowered him to the floor, and she began CPR. LVN A stated a CNA went to retrieve EMS personnel who were in another room, and they arrived shortly afterward and took over the assessment and resuscitation efforts. LVN A stated she did not observe any food in the room or in Resident #1's mouth when she entered. LVN A stated she knew Resident #1 required assistance with eating, but she was not aware of a history of choking on food. LVN A added that Resident #1 had a mechanical soft diet, and she assumed there may have been some issue in the past related to his diet. LVN A stated she did not observe the Dietary Manager bring a tray into Resident #1's room and stated she did not provide Resident #1 with any food that night.Interview on 3/4/2026 at 4:49 PM, CNA A stated that on 2/28/2026 she observed LVN A in Resident #1's room speaking on the phone with Resident #1's Responsible Party (RP) on speaker. CNA A stated she entered the room to inform LVN A that the resident across the hall needed assistance. CNA A stated LVN A told her she would come after she finished in Resident #1's room. CNA A stated she then continued providing care to other residents assigned to her. CNA A stated that after some time, LVN A came out of Resident #1's room and she, LVN A, and CMA B went into the room of the resident across the hall to provide care. CNA A stated they remained in that room for approximately 30 minutes. CNA A stated that after finishing with the resident across the hall, she went to retrieve supplies and then went to Resident #1's room to feed him. CNA A stated that when she entered the room, she observed a tray with half of a sandwich on it that had been pushed away from the bed where Resident #1 could not reach it. CNA A stated that as she approached and called Resident #1's name, he did not respond. She stated she observed food sliding down the side of his mouth and the other half of the sandwich in his hand. CNA A stated she did not observe any rise and fall of the resident's chest and could not feel a pulse. CNA A stated she ran into the hallway and told two CNAs in the hall to get the nurse because Resident #1 was unresponsive. CNA A stated she returned to the room along with other staff who came in to assist. CNA A stated staff placed Resident #1 onto a backboard and lowered him to the ground. CNA A stated LVN A arrived and began CPR, and EMS personnel who were in Resident #2's room arrived shortly afterward and took over resuscitation efforts.CNA A recalled that earlier that evening, after an in-service conducted by the Dietary Manager, the Dietary Manager stated she had spoken with Resident #1's RP and was going to prepare food for Resident #1 and that he would need assistance with eating. CNA A stated she was busy caring for other residents that night and did not observe the tray being delivered to Resident #1's room. CNA A denied providing Resident #1 with any food prior to finding him unresponsive. CNA A stated that based on how she found Resident #1, it appeared that someone had already started feeding him. CNA A stated she was aware Resident #1 required assistance with eating, but she was not aware of the specific reason. CNA A stated she knew Resident #1 ate very slowly and that she typically stayed with him while he ate. CNA A stated she did not know who gave Resident #1 the sandwich.Interview on 3/4/2026 at 6:18 PM, the Administrator stated Resident #1 required minimal assistance due to vision impairment and that meals needed to be placed where the resident could see them. The Administrator stated Resident #1 required meal tray setup and believed it would have been safe to leave Resident #1 with a sandwich, as the resident was able to eat finger foods independently. The Administrator explained he was unsure where Resident #1 obtained the food he was eating, stating that family members frequently brought food to the facility or had food delivered for the resident. The Administrator stated he had been informed that the Dietary Manager told a CNA that Resident #1 would need assistance with eating, and that the Dietary Manager later brought a meal tray containing a sandwich to Resident #1's room. The Administrator stated the Dietary Manager reported she placed the tray in a location where Resident #1 could not reach it, and no staff reported feeding Resident #1 the sandwich. The Administrator further stated that the care plan interventions related to monitoring for dysphagia were from a previous issue when the resident had a G-tube removed and were no longer considered a concern. The Administrator stated he was not aware of any prior incidents of Resident #1 choking on food at the facility.Interview on 3/5/2026 at 11:52 AM, the Director of Rehabilitation (DOR) stated Resident #1 required verbal cueing and the meal tray to be placed within his visual field. The DOR stated Resident #1 sometimes needed assistance because he could become too tired or weak to bring utensils to his mouth while eating and would spill food. The DOR stated Resident #1 was better able to eat finger foods. The DOR stated she could not recall any previous instances of Resident #1 choking. The DOR stated that according to Resident #1's speech screening, dysphagia was noted when the resident consumed non-mechanical soft diets due to prolonged chewing time, but this issue was not observed when the resident was on a mechanical soft diet. The DOR further stated she did not recall the RP expressing concerns about choking, and stated that if the resident was not receiving rehabilitation services, she would not have been present at the care plan meeting or informed of any such concerns.Interview on 3/5/2026 at 12:41PM, the MDS Coordinator stated Resident #1's care plan included a focus area for potential nutritional problems was standard for a patient with his conditions. The MDS Coordinator stated Resident # 1 needed partial to moderate assistance with eating and stated if Resident #1 had a history of choking, then he was at risk and staff needed to watch for that. The MDS Coordinator stated nurses and any other staff positions who provided care to residents were designated to review care plans. The MDS Coordinator stated if a resident was diagnosed with dysphagia and had a history and risk of choking, the resident's care plan should have reflected that information. The diagnosis and history should have been indicated in resident care plans so the aides who provided care were able to see this information in the resident's electronic health record. The MDS Coordinator stated she was responsible for care plans. She said care plans were updated annually, and she reviewed residents records every morning for any changes in condition to be added to care plans as needed.Interview on 3/5/2026 at 12:54 PM, the Responsible Party (RP) stated Resident #1 had experienced two previous choking incidents at the facility. The RP stated that during a care plan meeting, she requested that designated staff feed the resident, as she had concerns about Resident #1 choking and not eating. The RP further stated she repeatedly informed the facility that Resident #1 could not feed himself without staff assistance and needed to be monitored while eating. The RP stated the facility reassured her not to worry and told her they would assign a designated staff member each shift to assist and monitor Resident #1 during meals.Interview on 3/5/2026 at 1:56 PM, the MD stated that given Resident #1's history, staff should not leave or walk away from the resident while he is eating, as he required monitoring to ensure he did not choke.Interview on 3/5/2026 at 2:20 PM, the Administrator stated that based on what staff had told him about Resident #1, it would have been safe to leave Resident #1 alone with a sandwich. The Administrator stated Resident #1 only required assistance with meal tray setup, including placing the tray within his line of sight and assistance with utensils. The Administrator further stated that Resident #1 was able to eat finger foods independently. The Administrator stated he was not aware of any previous choking or coughing incidents related to food involving Resident #1. Interview on 3/5/2026 at 2:50 PM, CMA B stated she feeds Resident #1 when she works with him because Resident #1 becomes weak and tired after dialysis and could fall asleep while trying to eat. CMA B stated she would not want him to fall asleep while eating because he could choke. CMA B stated she did not work with Resident #1 on 3/28/2026, but she was waved over by CNA A for assistance after CNA A found Resident #1 unresponsive. CMA B stated she entered Resident #1's room to see what was happening and observed him lying in bed with foam coming from his mouth. CMA B stated she immediately ran out of the room and down the hall to get the nurse.Interview on 3/5/2026 at 3:32 PM with the Administrator and Director of Nursing (DON) revealed the Administrator stated he did not believe Resident #1 choked on food on 2/28/2026. The Administrator stated that, based on the hospital records and how the resident was found, he suspected the resident went into cardiac arrest. The DON stated he agreed that Resident #1 may have either experienced cardiac arrest or a pulmonary embolism, both of which can occur without warning and cause sudden unresponsiveness. The Administrator further stated that when someone is choking, it is typically a violent event in which the person is thrashing while attempting to clear their airway, and their surrounding environment would likely be disrupted. The Administrator stated that, based on this belief, the resident would not have still had the sandwich in his hand if choking had occurred. The DON stated he agreed with the Administrator's statement.Interview on 3/5/2026 at 4:04 PM, EMS stated that while they were assisting another resident in the facility, a staff member entered the room and informed them that another resident was choking and requested assistance. EMS stated he immediately followed facility staff to Resident #1's room, where Resident #1 was observed lying on the ground on a backboard with facility staff surrounding him. EMS reported that Resident #1 was unresponsive, without a pulse, and not breathing. EMS further stated that when he assessed Resident #1's airway, it was completely obstructed by large amounts of vomit. EMS reported he had to obtain suction equipment to clear the airway and suctioned large white, creamy chunks from Resident #1's mouth, airway, and vocal cords. The EMS technician stated that the large white, creamy chunks did not appear to be gastric contents or bodily fluids, but instead appeared to be food material. EMS stated that based on how Resident #1 was found and the presence of food lodged in the airway and vocal cords, it was very likely the resident had been choking prior to going into cardiac arrest.Interview on 3/6/2026 at 8:22 AM, CNA A stated she has access to the care plans at nurse station on the computer. CNA A stated if Resident # 1 did not want to eat or had any concerns she would verbally report to the nurse and was not aware of any documentation requirement for choking or monitoring for risk of choking. CNA A stated she was not aware of Resident # 1's diagnosis of dysphagia and did not know all his conditions. CNA A stated the only charting she was aware of was on the wall system or the nurses station at the computer and CNA's would click that an ADL was completed like a bath, or incontinent care. CNA A stated she was only told to feed Resident #1 however was not told why or of any previous history of choking.Interview on 3/6/2026 at 11:31AM, the MDS Coordinator stated Resident # 1 next care plan review date would be April 2026 and his diet for mechanical soft would not be added in the care plan because it was not a treatment. The MDS Coordinator stated if there was a progress note about Resident # 1 diagnosis of dysphagia and the mechanical soft diet being a part of that diagnosis, then the information would be added to the care plan under a new focus or section. The MDS Coordinator stated diagnoses that are active are care planned and if there is a treatment for that diagnosis it is also included. The MDS Coordinator stated if she was aware of previous choking history with Resident # 1, she would have noted the progress note of the incident and added the goals and/or interventions in the care plan. The MDS Coordinator stated the care plan goal and/or intervention would include swallow evaluations and that Resident #1 diet was downgraded. The MDS Coordinator stated care plan meetings include Therapy Services, RN, Dietary, Activities, CNA, Social Worker, Administrator however she is not present in the meetings and looks at the notes after the care plan meeting is completed.Record review of facility undated Comprehensive Care Plans policy revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. An IJ was identified on 3/6/2026 at 7:15pm. The IJ template was provided to the Administrator on 3/6/2026 at 7:15pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 3/8/2026 at 2:22pm.Plan to remove immediate jeopardy8 March 2026Facility ActionsF-656The facility failed to develop and implement a plan of care to include goals and interventions related to Resident #1's diagnosis of dysphagia or meal assistance.Resident #1 had a history of choking on food, a diagnosis of dysphagia and required assistance with eating.An emergency AD HOC QAPI meeting was held, and the issues thoroughly discussedAssociate medical Director informed. Completed 6 March 2026. Outcome: In-services for: Therapeutic Diet Orders, Meal S

Based on observation, interview and record review, the facility failed to ensure that residents received adequate supervision to prevent avoidable accidents for 1 of 8 residents reviewed for accidents (Resident #1) in that: Resident #1 who had a history of choking on food, a diagnosis of dysphagia and required supervision and assistance with eating was given a sandwich and left alone in his bedroom. Approximately 24 minutes after Resident #1 was left alone with a sandwich, he was found by CNA A unresponsive in his room with the sandwich in his hand and food leaking from his mouth. EMS had to clear Resident #1's airway by suctioning emesis (vomit) from his airway and vocal cords, initiated CPR and intubated him. Life saving measures were continued for Resident #1 as he was transported to the hospital and was pronounced deceased . An Immediate Jeopardy (IJ) was identified on 3/6/2026 at 7:15pm. While the IJ was removed on 3/9/2026, the facility remained out of compliance at a severity level of no actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for experiencing worsening of condition, hospitalization, choking and/or death.Findings included:Record review of Resident #1's face sheet dated 3/5/2026 revealed he was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted on [DATE], and discharged to an Acute Care hospital on 3/1/2026. Diagnoses included End-Stage Renal Disease (final, permanent stage of chronic kidney disease, where kidneys can no longer function on their own), acquired absence of the right leg (post-traumatic or surgical loss of the limb of the right leg), acquired absence of the left leg (post-traumatic or surgical loss of the limb of the left leg), Type II diabetes mellitus (chronic high blood glucose from insulin resistance and relative insulin deficiency), dysphagia (difficulty swallowing), fatigue (overwhelming physical or mental exhaustion-that does not improve with rest), muscle weakness (a reduced capacity to exert force with muscles), reduced mobility (decline in the ability to move independently), need for assistance with personal care (essential assistance for seniors and individuals with disabilities), and dependence on renal dialysis (long-term reliance on hemodialysis or peritoneal dialysis to replace failed kidney function).Record review of Resident #1's undated dashboard page in the electronic record revealed special instructions stating, .ASSIST RESIDENT IN EATING DUE TO UNABLE TO SEE.Record review of Resident #1's Care Plan revised on 3/27/2024 revealed a focus area for potential nutritional problems (weight gain/loss) related to weakness, diabetes mellitus, dysphagia, and impaired cognition (noticeable declines in memory, language, thinking, and judgment). Interventions included monitoring, documenting, and reporting as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, multiple swallowing attempts, refusing to eat, and appearing concerned during meals.Record review of Resident #1's progress note dated 11/28/2024 at 9:46 AM noted the resident was coughing and possibly choking while being assisted with breakfast. It was further noted that upon assessment, resident was coughing and continued to spit up particles of food. The progress note indicated the NP was informed and ordered Zofran as needed for nausea and vomiting, as well as a diet change to mechanical soft and a Speech Evaluation.Record review of Resident #1's progress note dated 11/30/2024 at 1:47 PM noted, With regard to the incident of the resident choking on food, family is requesting the resident be supervised during meals at all times.Record review of Resident #1's progress note dated 12/1/2024 at 7:01 PM by SLP noted two attempts were made to assess the resident's swallowing skills; however, the resident refused lunch, and when the SLP attempted to observe dinner, the resident had already eaten. The SLP documented that nursing staff informed her the diet had been changed to mechanical soft by the NP, and the NP requested the resident be monitored during meals for safety.Record review of Resident #1's physician order initiated on 5/12/2025 revealed an order for a regular diet with mechanical soft texture and thin/regular consistency.Record review of Resident #1's Care Plan revised on 5/19/2025 revealed a focus area for ADL self-care performance deficit related to activity intolerance, confusion, limited mobility, left above-knee amputation, right below-knee amputation, ESRD, and impaired range of motion in bilateral upper extremities. Interventions revised on 8/20/2025 indicated the resident required partial/moderate staff assistance with eating.Record review of Resident #1's Speech Screening dated 6/12/2025 revealed he was screened after readmission from the hospital and was not recommended for speech therapy services because the assessment indicated he was at his previous baseline with no changes. The screening documented he tolerated his prescribed diet of regular texture with chopped meat. The screening further noted Resident #1, .continues to present similar oral dysphagia with regular texture without chopped meat due to prolonged chewing, reduced bolus formation, and delayed oral transit time. Chopped meat facilitates reduced time for the patient to manipulate food prior to swallowing.Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7/15, indicating severely impaired cognition.Further review of the MDS revealed:Adequate visionLimited range of motion in both upper extremitiesRequired partial/moderate assistance with eating The MDS also indicated Resident #1 was:Dependent for sit-to-lying, lying-to-sitting, and chair/bed transfersRequired substantial/maximum assistance to roll left and rightUnable to sit-to-stand or walk 10 feetFurther review indicated the resident was on a mechanically altered and therapeutic diet. Record review of Resident #1's progress note dated 12/18/2025 at 2:06 PM by the Registered Dietitian (RD) revealed the resident's diet remained regular diet, mechanical soft texture, thin/regular consistency, and he continued to require assistance with meal setup and feeding at lunch and dinner due to fatigue. The RD recommended assisting Resident #1 with meal setup and feeding during lunch and dinner.Record review of Resident #1's dietary profile assessment dated [DATE] revealed the resident's diet order remained regular diet, mechanical soft texture with thin liquids, and he required partial assistance with eating.Record review of Resident #1's Care Plan Meeting Summary dated 2/5/2026 revealed RP voiced concern about Resident #1's appetite and her ordering food for him but he was not being fed. Summary further noted that RP was told CNAs will attempt to feed resident, but he refuses to eat.Record review of Resident #1' progress note dated 2/28/2026 at 11:35 pm by LVN A noted, At about 23:30 (11:30PM), nurse was called from a room where she is attending to 911 situation with 911 dispatcher crew that resident is unresponsive. Nurse assessed resident no breathing, pulse, nurse Call for help and initiate CPR. The 911 dispatcher team that was in the other room came and took over from the nurse. Resident RP and spouse came while 911 team was working on resident. Another 911 call made for the other resident. 911 crew worked on the resident and pulse felt and was transported to hospital at 12:33am. Notification to NP, DON.Record review of Resident #1's progress note dated 2/28/2026 at 11:20pm by LVN A notes, Nurse checked on resident, at the beginning of the shift no discomfort observed. At approximately 10 PM writer was informed by another staff that resident RP needs to speak with the nurse. Nurse called RP and she asked how resident is doing and that she would like to speak to resident if he needs something to eat so she can order for delivery. Nurse asked the RP to hang up to enable nurse dial RP from resident room. Nurse went to resident room called RP from resident room and put the phone on speaker per resident request and nurse did. RP asked if she should order food for resident. Resident said no that he is okay. Nurse informed RP that the kitchen manager is in the building and met with resident and she is preparing food for resident. RP then said she will visit resident tomorrow. Nurse then asked assigned aide to assist resident with meal when the kitchen manager brings it to resident.Record review of EMS report for Resident #1 dated 3/1/2026 revealed upon assessment at 11:41pm Resident #1's airway was completely obstructed, his pulse and breathing were absent, and he was unresponsive. Also, upon assessment he had fluid loss of 100 - 500ml of emesis. Resident #1's primary impression was noted to be cardiac arrest. EMS report detailed Resident #1 went into cardiac arrest prior to EMS arrival and the arrest was not witnessed, CPR initiated on 2/28/2026 at 11:40pm. Resident #1's first monitored rhythm was Ventricular Fibrillation (a life-threatening heart rhythm emergency where the heart's lower chambers quiver chaotically instead of pumping blood, resulting in sudden cardiac arrest and loss of pulse. It requires immediate CPR and defibrillation (shock) to restore a normal rhythm). Cardiac arrest report further detailed EMS first initiated CPR and use of AED. According to the narrative in the EMS report they were in the facility responding to a call regarding another resident when a staff member entered the room and stated another resident at the facility (Resident #1) was found choking in his room. Resident #1 was found supine on the floor unresponsive, apneic (not breathing), and pulseless. The narrative detailed, .no obvious external injuries or bleeding observed upon visual inspection. Patient is unresponsive. Airway completely obstructed by emesis. hands only CPR was initiated. Oral suctioning performed and I-gel (supraglottic airway device designed for rapid, blind insertion to manage airways during resuscitation) was placed with manual ventilations via BVM initiated. Due to excessive vomiting, the I-gel removed and suctioning was continued. intubation was performed and successful. initial rhythm interpreted as asystole. Staff on scene stated they last spoke with Resident #1 approximately 30 minutes before finding him unresponsive. The narrative went on to detail interventions attempted with Resident #1 to stabilize him, it was noted he was eventually transported to the hospital while EMS continued lifesaving interventions. It was noted at arrival to the hospital CPR continued by hospital staff, but he was declared deceased .Record review of Resident #1's progress note dated 3/1/2026 at 1:24am by LVN A revealed Hospital called to report Resident #1 had passed away in the hospital.Record review of Resident #1 hospital record dated 3/1/26 revealed he arrived to the hospital with CPR in progress via EMS and he was last seen at baseline around 11:15pm. RP was present and voiced she was notified by facility staff Resident #1 was found unresponsive and may have been choking prior to the event. Hospital records detailed CPR was continued at hospital but Resident #1 was pronounced deceased at 1:16AM. Observation on 3/4/2026 at 1:16pm, Business Office Manager (BOM) displayed facility's video footage from 2/28/2026, review of video footage revealed approximately at:10:54pm LVN A was on the phone at the nurse's station10:59pm LVN A entered Resident #1's room11:04pm LVN A came out of Resident #1's room11:05pm Dietary Manager went into Resident #1's room carrying a meal tray11:07pm Dietary Manager came out of Resident #1's room and went down the hall11:21pm LVN A went down another hall with nurse cart11:31pm CNA A went into Resident #1's room11:32pm CNA A came out of Resident #1's room waving for help and then reentered Resident #1's room11:32pm LVN B went to Resident #1's room11:33pm LVN A came back down the hall and into Resident #1's room11:34pm CNA A came out of Resident #1's room and ran down the hall, she returned a few seconds later with EMS staff and they entered Resident #1's room at 11:35pm.Summary of the video footage included Resident #1 was brought a meal tray by Dietary Manager, Dietary Manager left the room and there was no clear footage of anyone else entering Resident #1's room again until CNA A entered approximately 24 minutes later. Interview on 3/4/2026 at 3:31 PM, the Dietary Manager stated she was at the facility on the night of 2/28/2026 conducting an in-service with nurses and CNAs regarding customer service and diet textures. The Dietary Manager stated she answered a call at the nurse's station around 11:00 PM from Resident #1's Responsible Party (RP), who was upset because Resident #1 had gone to dialysis earlier that day and had not eaten since returning to the facility. The Dietary Manager stated she told the RP she would ensure Resident #1 received food. The Dietary Manager stated she went to Resident #1's room and observed two untouched meal trays. She asked Resident #1 if he was hungry, and he responded yes and requested a turkey sandwich with cheese and mayonnaise. The Dietary Manager stated she removed the old trays and went to retrieve a sandwich for Resident #1. The Dietary Manager stated that while leaving the room to obtain the sandwich, she saw Resident #1's CNA (CNA A) and informed her that she was bringing Resident #1 a meal tray and that he would require assistance with eating. The Dietary Manager stated she returned to Resident #1's room with the requested sandwich and a banana from the earlier tray. The Dietary Manager stated she placed the tray on the bedside table near the door, which was not within the resident's reach. The Dietary Manager stated Resident #1 requested a soda with his meal, and she told him she would retrieve one and that the CNA would be in shortly to assist him with eating.The Dietary Manager stated that as she walked down the hall to get the soda, she heard a resident in the 100 hall calling for help. She stated the resident calling for help was her mother (Resident #2). The Dietary Manager stated she immediately went to the room to check on her mother, who was complaining of chest pain, and she alerted a nurse for assistance. The Dietary Manager stated she remained with Resident #2 while she was being assessed, and 911 was called. The Dietary Manager stated she remained at her mother's bedside until EMS arrived at approximately 11:15 PM. The Dietary Manager stated that while EMS was stabilizing her mother, MA B entered the room and asked if one of the paramedics could come with her because Resident #1 had been found unresponsive when CNA went to feed him. The Dietary Manager stated one paramedic left the room with the CNA to check on Resident #1, while the remaining paramedic later wheeled Resident #2 down the hall to Resident #1's room so he could also assist. The Dietary Manager stated additional paramedics later arrived and transported Resident #2 to the hospital, while the original EMS crew remained with Resident #1. The Dietary Manager stated that to her knowledge, Resident #1 required assistance with eating due to vision impairment, but she believed he was able to eat finger foods independently. The Dietary Manager stated she was not aware of Resident #1 having a history of choking on food.Interview on 3/4/2026 at 3:59 PM, LVN A stated she worked the 6:00 PM-6:00 AM shift on 2/28/2026, and Resident #1 was assigned to her. LVN A stated Resident #1 had gone to dialysis earlier that day, and when he returned he was tired and did not want to eat. LVN A stated that later that night she was informed by the Dietary Manager that she needed to call Resident #1's Responsible Party (RP). LVN A stated she immediately called the RP, who requested to speak with Resident #1. LVN A stated she hung up the phone and then called the RP again from Resident #1's room, allowing them to speak on speakerphone at the resident's request. LVN A stated the RP asked Resident #1 if he wanted her to have food delivered, and Resident #1 said no. LVN A stated she reassured the RP that the Dietary Manager was bringing Resident #1 something to eat. LVN A stated that after Resident #1 finished speaking with the RP, she hung up the phone and left the room. LVN A stated she informed CNA A that the Dietary Manager was bringing food for Resident #1 and that CNA A would need to assist him with eating. LVN A stated that shortly afterward, a resident across the hall required assistance, and she, CNA A, and MA B went into that resident's room to provide care for approximately 10 minutes. LVN A stated that when she left the room across the hall, she looked into Resident #1's room and did not observe a meal tray in the room at that time. LVN A stated she continued down the hall when LVN B approached her regarding Resident #2 experiencing chest pain, and she went to assist in Resident #2's room.LVN A stated she remained in Resident #2's room assisting until EMS arrived. LVN A stated that while she was giving report to EMS, she heard her name being called and went into the hallway where staff directed her to Resident #1's room. LVN A stated she entered Resident #1's room and observed the resident to be unresponsive with no pulse. LVN A stated she performed a mouth sweep, but nothing was removed. LVN A stated she and the CNAs placed a backboard under Resident #1, lowered him to the floor, and she began CPR. LVN A stated a CNA went to retrieve EMS personnel who were in another room, and they arrived shortly afterward and took over the assessment and resuscitation efforts. LVN A stated she did not observe any food in the room or in Resident #1's mouth when she entered. LVN A stated she knew Resident #1 required assistance with eating, but she was not aware of a history of choking on food. LVN A added that Resident #1 had a mechanical soft diet, and she assumed there may have been some issue in the past related to his diet. LVN A stated she did not observe the Dietary Manager bring a tray into Resident #1's room and stated she did not provide Resident #1 with any food that night.Interview on 3/4/2026 at 4:49 PM, CNA A stated that on 2/28/2026 she observed LVN A in Resident #1's room speaking on the phone with Resident #1's Responsible Party (RP) on speaker. CNA A stated she entered the room to inform LVN A that the resident across the hall needed assistance. CNA A stated LVN A told her she would come after she finished in Resident #1's room. CNA A stated she then continued providing care to other residents assigned to her. CNA A stated that after some time, LVN A came out of Resident #1's room and she, LVN A, and MA B went into the room of the resident across the hall to provide care. CNA A stated they remained in that room for approximately 30 minutes. CNA A stated that after finishing with the resident across the hall, she went to retrieve supplies and then went to Resident #1's room to feed him. CNA A stated that when she entered the room, she observed a tray with half of a sandwich on it that had been pushed away from the bed where Resident #1 could not reach it. CNA A stated that as she approached and called Resident #1's name, he did not respond. She stated she observed food sliding down the side of his mouth and the other half of the sandwich in his hand. CNA A stated she did not observe any rise and fall of the resident's chest and could not feel a pulse. CNA A stated she ran into the hallway and told two CNAs in the hall to get the nurse because Resident #1 was unresponsive. CNA A stated she returned to the room along with other staff who came in to assist. CNA A stated staff placed Resident #1 onto a backboard and lowered him to the ground. CNA A stated LVN A arrived and began CPR, and EMS personnel who were in Resident #2's room arrived shortly afterward and took over resuscitation efforts.CNA A recalled that earlier that evening, after an in-service conducted by the Dietary Manager, the Dietary Manager stated she had spoken with Resident #1's RP and was going to prepare food for Resident #1 and that he would need assistance with eating. CNA A stated she was busy caring for other residents that night and did not observe the tray being delivered to Resident #1's room. CNA A denied providing Resident #1 with any food prior to finding him unresponsive. CNA A stated that based on how she found Resident #1, it appeared that someone had already started feeding him. CNA A stated she was aware Resident #1 required assistance with eating, but she was not aware of the specific reason. CNA A stated she knew Resident #1 ate very slowly and that she typically stayed with him while he ate. CNA A stated she did not know who gave Resident #1 the sandwich.Interview on 3/4/2026 at 6:18 PM, the Administrator stated Resident #1 required minimal assistance due to vision impairment and that meals needed to be placed where the resident could see them. The Administrator stated Resident #1 required meal tray setup and believed it would have been safe to leave Resident #1 with a sandwich, as the resident was able to eat finger foods independently. The Administrator explained he was unsure where Resident #1 obtained the food he was eating, stating that family members frequently brought food to the facility or had food delivered for the resident. The Administrator stated he had been informed that the Dietary Manager told a CNA that Resident #1 would need assistance with eating, and that the Dietary Manager later brought a meal tray containing a sandwich to Resident #1's room. The Administrator stated the Dietary Manager reported she placed the tray in a location where Resident #1 could not reach it, and no staff reported feeding Resident #1 the sandwich. The Administrator further stated that the care plan interventions related to monitoring for dysphagia were from a previous issue when the resident had a G-tube removed and were no longer considered a concern. The Administrator stated he was not aware of any prior incidents of Resident #1 choking on food at the facility.Interview on 3/5/2026 at 11:52 AM, the Director of Rehabilitation (DOR) stated Resident #1 required verbal cueing and the meal tray to be placed within his visual field. The DOR stated Resident #1 sometimes needed assistance because he could become too tired or weak to bring utensils to his mouth while eating and would spill food. The DOR stated Resident #1 was better able to eat finger foods. The DOR stated she could not recall any previous instances of Resident #1 choking. The DOR stated that according to Resident #1's speech screening, dysphagia was noted when the resident consumed non-mechanical soft diets due to prolonged chewing time, but this issue was not observed when the resident was on a mechanical soft diet. The DOR further stated she did not recall the RP expressing concerns about choking, and stated that if the resident was not receiving rehabilitation services, she would not have been present at the care plan meeting or informed of any such concerns.Interview on 3/5/2026 at 12:54 PM, the Responsible Party (RP) stated Resident #1 had experienced two previous choking incidents at the facility. The RP stated that during a care plan meeting, she requested that designated staff feed the resident, as she had concerns about Resident #1 choking and not eating. The RP further stated she repeatedly informed the facility that Resident #1 could not feed himself without staff assistance and needed to be monitored while eating. The RP stated the facility reassured her not to worry and told her they would assign a designated staff member each shift to assist and monitor Resident #1 during meals.Interview on 3/5/2026 at 1:56 PM, the MD stated that given Resident #1's history, staff should not leave or walk away from the resident while he was eating, as he required monitoring to ensure he did not choke.Interview on 3/5/2026 at 2:20 PM, the Administrator stated that based on what staff had told him about Resident #1, it would have been safe to leave Resident #1 alone with a sandwich. The Administrator stated Resident #1 only required assistance with meal tray setup, including placing the tray within his line of sight and assistance with utensils. The Administrator further stated that Resident #1 was able to eat finger foods independently. The Administrator stated he was not aware of any previous choking or coughing incidents related to food involving Resident #1.Interview on 3/5/2026 at 2:50 PM, MA B stated she fed Resident #1 when she worked with him because Resident #1 became weak and tired after dialysis and would fall asleep while trying to eat. MA B stated she would not want him to fall asleep while eating because he could choke. MA B stated she did not work with Resident #1 on 2/28/2026, but she was waved over by CNA A for assistance after CNA A found Resident #1 unresponsive. MA B stated she entered Resident #1's room to see what was happening and observed him lying in bed with foam coming from his mouth. MA B stated she immediately ran out of the room and down the hall to get the nurse.Interview on 3/5/2026 at 3:32 PM with the Administrator and Director of Nursing (DON) revealed the Administrator stated he did not believe Resident #1 choked on food on 2/28/2026. The Administrator stated that, based on the hospital records and how the resident was found, he suspected the resident went into cardiac arrest. The DON stated he agreed that Resident #1 may have either experienced cardiac arrest or a pulmonary embolism, both of which can occur without warning and cause sudden unresponsiveness. The Administrator further stated that when someone is choking, it is typically a violent event in which the person is thrashing while attempting to clear their airway, and their surrounding environment would likely be disrupted. The Administrator stated that, based on this belief, the resident would not have still had the sandwich in his hand if choking had occurred. The DON stated he agreed with the Administrator's statement.Interview on 3/5/2026 at 4:04 PM, EMS stated that while they were assisting another resident in the facility, a staff member entered the room and informed them that another resident was choking and requested assistance. EMS stated he immediately followed facility staff to Resident #1's room, where Resident #1 was observed lying on the ground on a backboard with facility staff surrounding him. EMS reported that Resident #1 was unresponsive, without a pulse, and not breathing. EMS further stated that when he assessed Resident #1's airway, it was completely obstructed by large amounts of vomit. EMS reported he had to obtain suction equipment to clear the airway and suctioned large white, creamy chunks from Resident #1's mouth, airway, and vocal cords. The EMS technician stated that the large white, creamy chunks did not appear to be gastric contents or bodily fluids, but instead appeared to be food material. EMS stated that based on how Resident #1 was found and the presence of food lodged in the airway and vocal cords, it was very likely the resident had been choking prior to going into cardiac arrest.Record review of e-mail sent by surveyors on 3/4/2026 at 6:59pm to Administrator and BOM requested policies for Supervision, Monitoring, Accidents and Hazards. The facility provided policies on 3/5/2026 that did not address supervision of residents or information relevant to failures.An IJ was identified on 3/6/2026 at 7:15pm. The IJ template was provided to the Administrator on 3/6/2026 at 7:15pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 3/8/2026 at 2:22pm. Plan to remove immediate jeopardy8 March 2026Facility ActionsF-689The facility failed to adequately supervise Resident #1 while the resident ate a sandwich.Resident #1 had a history of choking on food, a diagnosis of dysphagia and required assistance with eating.An emergency AD HOC QAPI meeting was held, and the issues thoroughly discussed.Associate medical Director informed. Completed 6 March 2026. Outcome: In-services for: Therapeutic Diet Orders, Meal Supervision and Assistance, Care Planning - IDT, Accessing Resident Care Information in resident electronic health records, Accessing the Resident Care Plan in resident electronic health records, Administrator, DOR, DON and their Designee reviewed supervision policies and outcome: Policy of Determination of Resident Supervision Needs During Meals and new process to assist staff in quickly identifying residents who require supervision or assistance during meal times. Administrator was in-serviced on: Therapeutic Diet orders, Care Planning, Accessing Resident Care Information in the CNA Kardex/POC, Accessing the Resident Care Plan in PCC by NP /RN on 6 March 2026.Resident #1 is no longer a resident at the facility.The facility has determined that all residents have the potential to be affected.Assessments and care plans for all Residents were reviewed to address chewing and swallowing difficulties, positioning, and supervision needs during meals. Revisions were made to reflect all current supervision and safety interventions. The revised assessments and care plans were reviewed with staff involved in the care of each resident. Will be Completed 7 March 2026, DON/Designee completed the audit. No additional residents were found to be affected.MDS, DON, Administrator, Nursing, CNA were in-serviced on the care plans. DON, Administrator and their designee will complete the in-services started 6 March 2026 and completed by 11 March 2026.New Policy: Determination of Resident Supervision Needs During MealsPolicy: Determination of Resident Supervision Needs During MealsPurpose:To ensure residents who require supervision during meals are identified promptly and appropriate safety measures are implemented until comprehensive assessments are completed.Policy:Upon admission or readmission to the facility, available clinical documentation will be reviewed to determine whether a resident requires supervision during meals. An initial determination will be made by the Director of Nursing (DON), Therapy, Administrator, or their designee based on the information available at the time of admission.Residents who are determined to require supervision during meals will be identified within the PointClickCare (PCC) system by being placed in Position 2 of the room assignment. This designation serves as a visual identifier for staff and will populate in multiple areas of the electronic medical record, including but not limited to: Resident list Resident chart eMAR Point of Care (POC)This process assists staff in quickly identifying residents who require supervision or assistance during meal times.If a resident is initially determined not to require supervision but staff later identify a concern related to the resident's ability to safely eat independently unsupervised, any staff member may notify the DON, Therapy, Administrator, or their designee for review. The resident may be placed under supervision status pending further clinical assessment and evaluation.Dietary Communication:Any change to a resident's diet type, food texture, liquid consistency, or supervision status during meals must be communicated to Dietary. A Dietary Communication Form will be completed, signed, and provided to the Dietary Department to ensure appropriate updates are made within the dietary system and that correct meal service is provided.Follow-Up Assessments:Further assessments by Nursing and/or Therapy will be completed as appropriate to determine the resident's ongoing needs for supervision or assistance with eating.Staff Responsibility During Meal Service:The identification of a resident as requiring supervision during meals through the PointClickCare (PCC) system and/or the dietary meal ticket system serves as a communication tool for staff. However, direct care staff assigned to the resident remain responsible for ensuring appropriate supervision and diet is provided during meal service.Staff will verify the resident's diet order, texture, liquid consistency, and supervision requirements prior to meal service. Any discrepancies identified will be immediately reported to the DON, charge nurse, Therapy, Administrator, or designee for review and correction. Completed 7 March 2026 Policy was cr

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting of alleged violations.The facility failed to report Resident #1's suspicious death to the State Agency within the required 2-hour timeframe after allegation made by RP and/or suspicion was formed after Resident #1, who required assistance with eating, was found unresponsive in bed with half a sandwich in his hand and chewed food present on the side of his mouth.Resident #1 never regained consciousness after being found unresponsive and was later pronounced deceased at the hospital. Resident #1's RP expressed concerns to facility staff that Resident #1 may have choked prior to being found unresponsive and that the staff's response may have contributed to his deathThe facility's failure to report this incident as required prevented timely investigation of a potential neglect related event and placed residents at risk for unrecognized and ongoing neglect, which could result in serious injury, diminished quality of life, or death.Findings included: Record review of Resident #1's face sheet dated 3/5/2026 revealed he was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted on [DATE], and discharged to an Acute Care hospital on 3/1/2026. Diagnoses included End-Stage Renal Disease (final, permanent stage of chronic kidney disease, where kidneys can no longer function on their own), acquired absence of the right leg (post-traumatic or surgical loss of the limb of the right leg), acquired absence of the left leg (post-traumatic or surgical loss of the limb of the left leg), Type II diabetes mellitus (chronic high blood glucose from insulin resistance and relative insulin deficiency), dysphagia (difficulty swallowing), fatigue (overwhelming physical or mental exhaustion-that does not improve with rest), muscle weakness (a reduced capacity to exert force with muscles), reduced mobility (decline in the ability to move independently), need for assistance with personal care (essential assistance for seniors and individuals with disabilities), and dependence on renal dialysis (long-term reliance on hemodialysis or peritoneal dialysis to replace failed kidney function).Record review of Resident #1's undated dashboard page in the electronic record revealed special instructions stating, .ASSIST RESIDENT IN EATING DUE TO UNABLE TO SEE.Record review of Resident #1's Care Plan revised on 3/27/2024 revealed a focus area for potential nutritional problems (weight gain/loss) related to weakness, diabetes mellitus, dysphagia, and impaired cognition (noticeable declines in memory, language, thinking, and judgment). Interventions included monitoring, documenting, and reporting as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, multiple swallowing attempts, refusing to eat, and appearing concerned during meals.Record review of Resident #1's Care Plan revised on 5/19/2025 revealed a focus area for ADL self-care performance deficit related to activity intolerance, confusion, limited mobility, left above-knee amputation, right below-knee amputation, ESRD, and impaired range of motion in bilateral upper extremities. Interventions revised on 8/20/2025 indicated the resident required partial/moderate staff assistance with eating.Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7/15, indicating severely impaired cognition.Further review of the MDS revealed:Adequate visionLimited range of motion in both upper extremitiesRequired partial/moderate assistance with eating The MDS also indicated Resident #1 was:Dependent for sit-to-lying, lying-to-sitting, and chair/bed transfersRequired substantial/maximum assistance to roll left and rightUnable to sit-to-stand or walk 10 feetFurther review indicated the resident was on a mechanically altered and therapeutic diet.Record review of Resident #1's progress note dated 12/18/2025 at 2:06 PM by the Registered Dietitian (RD) revealed the resident's diet remained regular diet, mechanical soft texture, thin/regular consistency, and he continued to require assistance with meal setup and feeding at lunch and dinner due to fatigue. The RD recommended assisting Resident #1 with meal setup and feeding during lunch and dinner.Record review of Resident #1's dietary profile assessment dated [DATE] revealed the resident's diet order remained regular diet, mechanical soft texture with thin liquids, and he required partial assistance with eating.Record review of Resident #1's Care Plan Meeting Summary dated 2/5/2026 revealed RP voiced concern about Resident #1's appetite and her ordering food for him but he is not being fed. Summary further noted that RP was told CNA's will attempt to feed resident, but he refuses to eat.Record review of Resident #1' progress note dated 2/28/2026 at 11:35am by LVN A noted, At about 23:30 (11:30PM), nurse was called from a room where she is attending to 911 situation with 911 dispatcher crew that resident is unresponsive. Nurse assessed resident no breathing, pulse, nurse Call for help and initiate CPR. The 911 dispatcher team that was in the other room came and took over from the nurse. Resident RP and spouse came while 911 team was working on resident. Another 911 call made for the other resident. 911 crew worked on the resident and pulse felt and was transported to hospital at 12:33am. Notification to NP, DON.Record review of Resident #1's progress note dated 2/28/2026 at 11:20pm by LVN A notes, Nurse checked on resident, at the beginning of the shift no discomfort observed. At approximately past 10 PM writer was informed by another staff that resident RP needs to speak with the nurse. Nurse called RP and she asked how resident is doing and that she would like to speak to resident if he needs something to eat so she can order for delivery. Nurse asked the RP to hang up to enable nurse dial RP from resident room. Nurse went to resident room called RP from resident room and put the phone on speaker per resident request and nurse did. RP asked if she should order food for resident. Resident said no that he is okay. Nurse informed RP that the kitchen manager is in the building and met with resident and she is preparing food for resident. RP then said she will visit resident tomorrow. Nurse then asked assigned aide to assist resident with meal when the kitchen manager brings it to resident.Record review of EMS report for Resident #1 dated 3/1/2026 revealed upon assessment at 11:41pm Resident #1's airway was completely obstructed, his pulse and breathing were absent, and he was unresponsive. Also, upon assessment he had fluid loss of 100 - 500ml of emesis. Resident #1's primary impression was noted to be cardiac arrest. EMS report detailed Resident #1 went into cardiac arrest prior to EMS arrival and the arrest was not witnessed, CPR initiated on 2/28/2026 at 11:40pm. Resident #1's first monitored rhythm was Ventricular Fibrillation (a life-threatening heart rhythm emergency where the heart's lower chambers quiver chaotically instead of pumping blood, resulting in sudden cardiac arrest and loss of pulse. It requires immediate CPR and defibrillation (shock) to restore a normal rhythm). Cardiac arrest report further detailed EMS first initiated CPR and use of AED. According to the narrative in the EMS report they were in the facility responding to a call regarding another resident when a staff member entered the room and stated another resident at the facility (Resident #1) was found choking in his room. Resident #1 was found supine on the floor unresponsive, apneic (not breathing), and pulseless. The narrative detailed, .no obvious external injuries or bleeding observed upon visual inspection. Patient is unresponsive. Airway completely obstructed by emesis. hands only CPR was initiated. Oral suctioning performed and I-gel (supraglottic airway device designed for rapid, blind insertion to manage airways during resuscitation) was placed with manual ventilations via BVM initiated. Due to excessive vomiting, the I-gel removed and suctioning was continued. intubation was performed and successful. initial rhythm interpreted as asystole. Staff on scene stated they last spoke with Resident #1 approximately 30 minutes before finding him unresponsive. The narrative went on to detail interventions attempted with Resident #1 to stabilize him, it was noted he was eventually transported to the hospital while EMS continued lifesaving interventions. It was noted at arrival to the hospital CPR continued by hospital staff, but he was declared deceased .Record review of Resident #1's progress note dated 3/1/2026 at 1:24am by LVN A revealed Hospital called to report Resident #1 had passed away in the hospital.Record review of Resident #1 hospital record dated 3/1/26 revealed he arrived at the hospital with CPR in progress via EMS and he was last seen at baseline around 11:15pm. RP was present and voiced she was notified by facility staff Resident #1 was found unresponsive and may have been choking prior to the event. Hospital records detailed CPR was continued at hospital but Resident #1 was pronounced deceased at 1:16AM.Observation on 3/4/2026 at 1:16pm, Business Office Manager (BOM) displayed facility's video footage from 2/28/2026, review of video footage revealed approximately at:10:54pm LVN A was on the phone at the nurse's station10:59pm LVN A entered Resident #1's room11:04pm LVN A came out of Resident #1's room11:05pm Dietary Manager went into Resident #1's room carrying a meal tray11:07pm Dietary Manager came out of Resident #1's room and went down the hall11:21pm LVN A went down another hall with nurse cart11:31pm CNA A went into Resident #1's room11:32pm CNA A came out of Resident #1's room waving for help and then reentered Resident #1's room11:32pm RN A went to Resident #1's room11:33pm LVN A came back down the hall and into Resident #1's room11:34pm CNA A came out of Resident #1's room and ran down the hall, she returned a few seconds later with EMS staff and they entered Resident #1's room at 11:35pm.Summary of the video footage included Resident #1 was brought a meal tray by Dietary Manager, Dietary Manager left the room and there was no clear footage of anyone else entering Resident #1's room again until CNA A entered approximately 24 minutes later.Interview on 3/4/2026 at 3:31 PM, The Dietary Manager stated she went to Resident #1's room and observed two untouched meal trays. She asked Resident #1 if he was hungry, and he responded yes and requested a turkey sandwich with cheese and mayonnaise. The Dietary Manager stated she removed the old trays and went to retrieve a sandwich for Resident #1. The Dietary Manager stated that while leaving the room to obtain the sandwich, she saw Resident #1's CNA (CNA A) and informed her that she was bringing Resident #1 a meal tray and that he would require assistance with eating. The Dietary Manager stated she returned to Resident #1's room with the requested sandwich and a banana from the earlier tray. The Dietary Manager stated she placed the tray on the bedside table near the door, which was not within the resident's reach. The Dietary Manager stated Resident #1 requested a soda with his meal, and she told him she would retrieve one and that the CNA would be in shortly to assist him with eating.The Dietary Manager stated that as she walked down the hall to get the soda, she heard a resident in the 100 hall calling for help. She stated the resident calling for help was her mother (Resident #2). The Dietary Manager stated she immediately went to the room to check on her mother, who was complaining of chest pain, and she alerted a nurse for assistance. The Dietary Manager stated she remained with Resident #2 while she was being assessed, and 911 was called. The Dietary Manager stated she remained at her mother's bedside until EMS arrived at approximately 11:15 PM. The Dietary Manager stated that while EMS was stabilizing her mother, CMA B entered the room and asked if one of the paramedics could come with her because Resident #1 had been found unresponsive when CNA went to feed him. The Dietary Manager stated one paramedic left the room with the CNA to check on Resident #1, while the remaining paramedic later wheeled Resident #2 down the hall to Resident #1's room so he could also assist. The Dietary Manager stated additional paramedics later arrived and transported Resident #2 to the hospital, while the original EMS crew remained with Resident #1. The Dietary Manager stated that to her knowledge, Resident #1 required assistance with eating due to vision impairment, but she believed he was able to eat finger foods independently. The Dietary Manager stated she was not aware of Resident #1 having a history of choking on food.Interview on 3/4/2026 at 3:59 PM, LVN A stated she worked the 6:00 PM-6:00 AM shift on 2/28/2026, and Resident #1 was assigned to her. LVN A stated she called Resident #1 RP, who requested to speak with Resident #1. LVN A stated she hung up the phone and then called the RP again from Resident #1's room, allowing them to speak on speakerphone at the resident's request. LVN A stated the RP asked Resident #1 if he wanted her to have food delivered, and Resident #1 said no. LVN A stated she reassured the RP that the Dietary Manager was bringing Resident #1 something to eat. LVN A stated that after Resident #1 finished speaking with the RP, she hung up the phone and left the room. LVN A stated she informed CNA A that the Dietary Manager was bringing food for Resident #1 and that CNA A would need to assist him with eating. LVN A stated that shortly afterward, a resident across the hall required assistance, and she, CNA A, and CMA B went into that resident's room to provide care for approximately 10 minutes. LVN A stated that when she left the room across the hall, she looked into Resident #1's room and did not observe a meal tray in the room at that time. LVN A stated she continued down the hall when RN A approached her regarding Resident #2 experiencing chest pain, and she went to assist in Resident #2's room.LVN A stated she remained in Resident #2's room assisting until EMS arrived. LVN A stated that while she was giving report to EMS, she heard her name being called and went into the hallway where staff directed her to Resident #1's room. LVN A stated she entered Resident #1's room and observed the resident to be unresponsive with no pulse. LVN A stated she performed a mouth sweep, but nothing was removed. LVN A stated she and the CNAs placed a backboard under Resident #1, lowered him to the floor, and she began CPR. LVN A stated a CNA went to retrieve EMS personnel who were in another room, and they arrived shortly afterward and took over the assessment and resuscitation efforts. LVN A stated she did not observe any food in the room or in Resident #1's mouth when she entered. LVN A stated she knew Resident #1 required assistance with eating, but she was not aware of a history of choking on food. LVN A added that Resident #1 had a mechanical soft diet, and she assumed there may have been some issue in the past related to his diet. LVN A stated she did not observe the Dietary Manager bring a tray into Resident #1's room and stated she did not provide Resident #1 with any food that night.Interview on 3/4/2026 at 4:49 PM, CNA A stated after LVN A came out of Resident #1's room and finished talking with him and his RP, she, LVN A, and CMA B went into the room of the resident across the hall to provide care. CNA A stated they remained in that room for approximately 30 minutes. CNA A stated that after finishing with the resident across the hall, she went to retrieve supplies and then went to Resident #1's room to feed him. CNA A stated that when she entered the room, she observed a tray with half of a sandwich on it that had been pushed away from the bed where Resident #1 could not reach it. CNA A stated that as she approached and called Resident #1's name, he did not respond. She stated she observed food sliding down the side of his mouth and the other half of the sandwich in his hand. CNA A stated she did not observe any rise and fall of the resident's chest and could not feel a pulse. CNA A stated she ran into the hallway and told two CNAs in the hall to get the nurse because Resident #1 was unresponsive. CNA A stated she returned to the room along with other staff who came in to assist. CNA A stated staff placed Resident #1 onto a backboard and lowered him to the ground. CNA A stated LVN A arrived and began CPR, and EMS personnel who were in Resident #2's room arrived shortly afterward and took over resuscitation efforts.CNA A recalled that earlier that evening, after an in-service conducted by the Dietary Manager, the Dietary Manager stated she had spoken with Resident #1's RP and was going to prepare food for Resident #1 and that he would need assistance with eating. CNA A stated she was busy caring for other residents that night and did not observe the tray being delivered to Resident #1's room. CNA A denied providing Resident #1 with any food prior to finding him unresponsive. CNA A stated that based on how she found Resident #1, it appeared that someone had already started feeding him. CNA A stated she was aware Resident #1 required assistance with eating, but she was not aware of the specific reason. CNA A stated she knew Resident #1 ate very slowly and that she typically stayed with him while he ate. CNA A stated she did not know who gave Resident #1 the sandwich.Interview on 3/4/2026 at 6:18 PM, the Administrator stated Resident #1 required minimal assistance due to vision impairment and that meals needed to be placed where the resident could see them. The Administrator stated Resident #1 required meal tray setup and believed it would have been safe to leave Resident #1 with a sandwich, as the resident was able to eat finger foods independently. The Administrator explained he was unsure where Resident #1 obtained the food he was eating, stating that family members frequently brought food to the facility or had food delivered for the resident. The Administrator stated he had been informed that the Dietary Manager told a CNA that Resident #1 would need assistance with eating, and that the Dietary Manager later brought a meal tray containing a sandwich to Resident #1's room. The Administrator stated the Dietary Manager reported she placed the tray in a location where Resident #1 could not reach it, and no staff reported feeding Resident #1 the sandwich. The Administrator further stated that the care plan interventions related to monitoring for dysphagia were from a previous issue when the resident had a G-tube removed and were no longer considered a concern. The Administrator stated he was not aware of any prior incidents of Resident #1 choking on food at the facility.Interview on 3/5/2026 at 12:54 PM, the Responsible Party (RP) stated Resident #1 had experienced two previous choking incidents at the facility. The RP stated that during a care plan meeting, she requested that designated staff feed the resident, as she had concerns about Resident #1 choking and not eating. The RP further stated she repeatedly informed the facility that Resident #1 could not feed himself without staff assistance and required monitoring while eating. The RP stated the facility reassured her not to worry and told her they would assign a designated staff member each shift to assist and monitor Resident #1 during meals. The RP stated she was notified that Resident #1 had been found unresponsive and immediately came to the facility. The RP stated that upon her arrival on 2/28/2026, EMS personnel were still providing care to Resident #1. The RP stated she immediately expressed concerns regarding the staff's response after Resident #1 was found unresponsive. The RP stated EMS personnel informed her that it was suspected Resident #1 had been choking and had vomited prior to being found unresponsive. The RP stated she questioned facility staff about how Resident #1 could have choked when he was supposed to be assisted and supervised during meals, but stated the facility did not acknowledge that choking had occurred.Interview on 3/5/2026 at 2:50 PM, CMA B stated she did not work with Resident #1 on 3/28/2026, but she was waved over by CNA A for assistance after CNA A found Resident #1 unresponsive. CMA B stated she entered Resident #1's room to see what was happening and observed him lying in bed with foam coming from his mouth. CMA B stated she immediately ran out of the room and down the hall to get the nurse.Interview on 3/5/2026 at 3:32 PM with the Administrator and DON revealed the Administrator stated he did not believe Resident #1 choked on food on 2/28/2026. The Administrator stated that, based on hospital records and how the resident was found, he believed the resident experienced cardiac arrest. The DON stated he agreed that Resident #1 may have experienced either cardiac arrest or a pulmonary embolism, both of which can occur without warning and result in sudden unresponsiveness. The Administrator further stated that choking is typically a violent event, during which an individual would be thrashing while attempting to clear their airway, and the surrounding environment would likely be disrupted. The Administrator stated that based on this belief, the resident would not have still had the sandwich in his hand if choking had occurred. The DON stated he agreed with the Administrator's statement. The Administrator stated that based on the facility's investigation, Resident #1 experienced cardiac arrest and did not choke, and therefore he did not consider the death to be reportable. The Administrator further stated he was able to access hospital records shortly after the incident, which assisted in his determination not to report the event. The Administrator and DON stated that, based on their recollection, the Responsible Party (RP) was upset regarding the staff's response when Resident #1 was found unresponsive and believed the resident had been left without intervention. They stated they determined this concern to be untrue and did not consider the circumstances surrounding Resident #1's death to be suspicious.Interview on 3/5/2026 at 4:04 PM, EMS stated that while they were assisting another resident in the facility, a staff member entered the room and informed them that another resident was choking and requested assistance. EMS stated he immediately followed facility staff to Resident #1's room, where Resident #1 was observed lying on the ground on a backboard with facility staff surrounding him. EMS reported that Resident #1 was unresponsive, without a pulse, and not breathing. EMS further stated that when he assessed Resident #1's airway, it was completely obstructed by large amounts of vomit. EMS reported he had to obtain suction equipment to clear the airway and suctioned large white, creamy chunks from Resident #1's mouth, airway, and vocal cords. The EMS technician stated that the large white, creamy chunks did not appear to be gastric contents or bodily fluids, but instead appeared to be food material. EMS stated that based on how Resident #1 was found and the presence of food lodged in the airway and vocal cords, it was very likely the resident had been choking prior to going into cardiac arrest. EMS recalled Resident #1 RP being present and upset with the facility regarding Resident #1 being found unresponsive and questioning the facility actions.Record review of facility's undated Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Further review of policy revealed, Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Facility policy also defined alleged violations as, A situation or occurrence that is observed or reported by staff, resident, relative, visitors or others but has not yet been investigated and, if verified, could be noncompliance with Federal requirements related to mistreatment, exploitation, neglect or abuse. The policy also noted, The Administrator of designee will notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery of forming suspicion.

Based on interviews and record review the facility failed to maintain acceptable parameters of nutritional status in such as usual body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicate otherwise for 1 of 5 (CR#1) residents reviewed for weight loss. -The facility failed to ensure CR#1 was monitored for weight loss resulting in a 19.7% or 17.2 lbs. in 3-month period. CR#1 was admitted to hospital with hypernatremia and generalized weakness and a 43-pound weight loss since her last hospitalization . -The facility failed to ensure CR#1 maintained acceptable parameters of nutritional status such as her usual body weight. CR#1 was admitted to hospital with hypernatremia and generalized weakness and a 43-pound weight loss since her last hospitalization -The facility failed to implement dietary recommendations. An Immediate Jeopardy (IJ) was identified on 11/8/2024 at 3:18 p.m. The IJ template was provided to the facility on [DATE] at 3:18pm, While the IJ was removed on 11/13/2024 at 3:29 p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm the facility continued to monitor the implementation and effectiveness of their corrective systems. Finding included: Record review of CR #1's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Alzheimer Disease (a progressive disease that destroys memory), cognitive communication deficit (a difficult with communication that is caused by a disruption in cognition), prediabetes, and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of CR#1's MDS dated [DATE] revealed: Section C500 -Brief interview of mental status was unscored. Section GG - Functional Abilities and Goals reflected: A. Eating, oral hygiene, toileting, showers, upper and lower body dressing all were coded as 01 (dependent-helper does all the effort). Section K- Swallowing/Nutritional Status revealed Swallowing Disorder was marked as Z. None of the above (loss of liquids, holding food in mouth, coughing, or choking or complaints of difficulty or pain with swallowing). Section I- Nutritional status 152600- Malnutrition had no entry or X for malnutrition risk. Record review revealed no significant change MDS was provided when CR#1's weight went from 87.2 lbs on 7/29/2024 to 71.6 lbs. on 8/28/2024. Record review of CR#1's discharge MDS dated [DATE] indicated Section GG- Functional abilities had a code change of (2)- which indicated the CR#1 required substantial or maximum assistance to eat (helper does more than half the effort). Section K- Swallowing/Nutrition indicated: Weight Loss a code of (2)- Yes, not on physician prescribed weight loss regiment. Section I- Nutritional status 152600- Malnutrition had no entry or X for malnutrition risk. Record review of CR#1's care plan dated 7/31/2024 and revised on 8/2/2024 reflected: CR#1 had a nutritional problem or potential nutritional problem r/t mechanically altered diet, Alzheimer disease, and prediabetes. Goal: CR#1 will maintain adequate nutritional and hydration status weight stable, no signs and symptoms of malnutrition or dehydration through review date of 11/9/2024. Interventions: Administer medications as ordered, monitor and document for side effects of effectiveness. Monitor/document/report PRN any signs and symptoms of dehydration. Monitor/record/report to MD PRN signs and symptoms of malnutrition: Emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months and >10% in 6 months. Record review of weight summary report revealed: 7/29/2024- CR #1 was 87.2 lbs. 8/28/2024- 71.6 lbs. 9/11/2024 - 75.6 lbs. 9/18/2024- 73.8 lbs. 10/7/2024- 70.0 lbs. Record review of dietician progress notes revealed on 8/1/2024: CR#1 estimated energy need was 1750 kcal, 65 grams of protein, fluids 1500 ml. CR#1 is 88% of DBW (desirable body weight) with poor intake. During RD rounds, a physical assessment was conducted. CR#1 was very thin stature, muscle wasting, as well as orbital subcutaneous fat wasting and appears to have a nutritional deficit. Resident is supplemented with Zinc and Vitamin C but may benefit from additional nutrients to support wound healing and weight repletion. CR#1 has a potential for desirable weight gain, weight fluctuation, and dehydration. Recommendation: 1. 2k cal house supplement, 90 ml TID after meals to promote weight repletion and maintenance, 2. Liquid protein 30ml BID for 90 days to support muscle mass and wound healing; (3) Juven/Arginaid plus 8 oz H20 BID for 30 days. Goal: Weight maintenance or steady weight gain of +4% by next review date. Will monitor clinical status, weights, labs intakes and skin. Record review of CR#1's MAR revealed: July 1-31, 2024- Thiamine HCI 50mg 1 time daily ordered, Rivastigmine/Patch 4.6mg/24-hour, Vitamin B 50 mg 1 time daily, Zinc Oral tablet 50 mg 1 time per day, Lidocaine patch 4% for pain, Lovastatin 40 mg daily, Aspirin 81mg 1 time daily, Acetaminophen 325 for pain every 6 hours and PRN, Ascorbic Acid 500 mg 1 time daily. August 1-31, 2024- all medications remained the same. September 1-31st - Thiamine HCI 50mg 1 time daily ordered, Rivastigmine/Patch 4.6mg/24-hour, Vitamin B 50 mg 1 time daily, Zinc Oral tablet 50 mg 1 time per day, Lidocaine patch 4% for pain, Lovastatin 40 mg daily, Aspirin 81mg 1 time daily, Acetaminophen 325 for pain every 6 hours and PRN, Ascorbic Acid 500 mg 1 time daily. Additional medications added in September were Ativan Oral Tablet 0.5 was ordered on 9/13/2024 and discontinued on 9/22/2024, Bisacodyl Rectal suppository 10 mg daily beginning 9/13/2024, Morphine Sulfate 20 mg and Promethazine 25mg daily for nausea. October 1-17, 2024- there were no new medications from [DATE] medication list. Record review of nursing progress notes revealed there were no progress notes indicating CR#1's weights were trending downward between 7/29/2024-10/7/2024. Record review of hospital admission paperwork revealed CR#1 was admitted to a local hospital on 10/17/2024. The principle or chief problem for admission was hypernatremia and generalized weakness. CR#1's weight upon admission was 55 lbs. and she was severely dehydrated. The recorded weights for CR#1's last three encounters at this local hospital were: 10/18/2024- 24.9 kg (55lbs) 7/26/2024 - 44.6 kg (98 lbs 6.4 oz) 2/16/2024 - 44 kg (97 lbs.) An interview with RN A on 11/1/2024 at 10:56a.m., revealed her to state she had been employed at the facility for 7 months. She said all of the nurses work different halls every shift. For example, one day she might be the nurse on Halls 100 and 200 and the next day 200 and 300 and so on. She said she did not work on the hall where CR#1 resided very often. She said she recalled CR#1 had a regular diet with puree texture and thickened liquids. She said her legs were contracted to her abdominal area (fetal position contracture). She said this made it dfifficult to tell she had loss weight. She denied being alerted by staff of CR#1's refusals to eat, loss of weight or other concerns. She said CR#1 liked sweets so if they added pudding to her food she would normally eat. She said she might not have eaten what was cooked for her, but she did eat. She looked in PCC and stated she did not see any nursing notes concerning her intake for the month of October, 2024. She said she would have documented any refusals and had the CNA's get her a substitution if she refused her meal. She stated if a resident does not eat, they will not get their daily nutritional and hydration needs met. She said she was not sure why CR#1 was losing weight. An interview with RN C at 11:17 a.m., revealed she had been employed for 3 months. She was responsible for halls 300 and 400 today. She said the other nurse is responsible for Halls 100 and 200 and the nurses usually worked 6am-6pm. She said there were 3 CNa's on the halls. She said she worked 10am-6pm shift. She said she was not too familiar with CR#1 and do not recall being told that CR#1 was not eating or refusing meals. She stated she would have alerted the interim DON, Administrator, Physician and family about the issue. An interview with CNA A on 11/1/2024 at 12:32 p.m. revealed CR#1 needed assistance with feedings. He said she had a pureed diet and preferred to eat in her room. CNA A stated CR#1 often did not want to eat as she would not open her mouth when staff put the spoon to her mouth. Further, that he would alert the on-duty nurse anytime she did not eat. He said he cannot recall how often she refused to eat. He said he documented refusals but always offered her a substitute. He said she liked applesauce and pudding. He stated CNA B was the lead CNA and she could usually get her to eat her meals. She was familiar with her from another facility. He said she did not refuse other ADL's such as brief changes and bed baths. During an interview with CR#1's FM on 11/1/2024 at 3:20 p.m. the FM said the facility was responsible for feeding CR#1 but every 2- or 3-days the FM came to visit, and she always asked about food that was still sitting on her table. She said the uneaten food sat well past the mealtimes such as 1 hour after breakfast and sometimes a couple of hours after lunch. She said when she spoke with the CNAs and nurses, she was told that she had substitutions, but did eat. The FM said she would try to get to the facility for her mealtimes just to observe, but the last few weeks she was unable to get there due to some personal issues. The FM said she took care of CR#1 for [AGE] years and she knew that she would eat if she had help with feedings that the facility said they would provide. The FM said staff were supposed to feed her as she was dependent. CR#1 could not feed herself. The FM said she spoke to the Social Services Director on several occasions to address the issue. She said she had only spoken to the DON once about CR#1 food intake and staff not feeding her but the DON never followed-up with her about it. Instead, the SSD became her point of contact as she learned that the DON was no longer employed at the facility since September 2024. The FM asked SSD about a feeding tube during a telephone care plan meeting. She said she told the SSD that she would also start researching peg tube feedings because she did not know the difference between a peg tube or g-tube and how it would affect a resident her age. The FM said she wanted CR#1 to eat or be fed by any means possible. The FM said during a visit on 10/17/2024, CR#1 was lethargic and appeared to be severely malnourished. The FM said she could tell by looking at CR#1 that she had loss more weight since she saw a few weeks ago. The FM said once again her lunch was still sitting on her table uneaten. She said she observed CNA A and nurses near their breakroom, and it infuriated her that staff were standing around while CR#1 had not been fed. She called 911 and had CR#1 sent to the ER at a local hospital. The FM said upon arrival at the ER she was told CR#1 was severely dehydrated. The FM said a nurse at the hospital stated due to the muscle wasting, and lethargic state it appeared that CR#1 had not eaten or had been given enough water in weeks. An interview with Tray Aide on 11/6/2024 at 9:40am, she stated he had been employed since [DATE]. She said the CNAs hand out trays, pick up trays, and pushcart back to the kitchen. She said CNAs were supposed to input how much the residents were eating. She can recall trays coming back with uneaten food for CR#1. She said some of the food would be eaten but the meat was mostly what she would not eat. She said the pureed bananas and applesauce were always eaten. She said anytime she saw her tray with uneaten food she would inform the Dietary manager. She said she was not responsible for documenting food intake. An interview with the SSD on 11/6/2024 at 10:03am, revealed her to state she had been employed at the facility for 2 years. She said she had been in contact with the family of CR#1. She said she had personally reported to the DON several times that they were concerned about the resident not eating. She said CR#1's FM had been concerned and she witnessed a call between FM and the former DON about placing a peg tube so the resident would get food. She said the former DON questioned the FM about placing her on hospice instead of a peg tube. She said as far she knew the FM was looking into her options of hospice companies around September 2024 sometime. She said the care plan meeting notes she found in PCC was held on 8/8/24 and the FM was not able to attend. She stated care plan meetings are quarterly unless there is a change in condition. She said she does not know why they would not have had another care plan meeting when CR#1 began to lose weight. An interview with the Dietician on 11/6/2024 at 11:45am she said she did rounds at the facility every Thursday. She said after she put in her recommendations for the MD she had to wait on an approval. She said she was not permitted to write any orders. All orders must come from the MD. She said she input recommendations for CR#1 in August 2024. She said she also sent the MD a letter which notified him that she had recommendations that he needed to approve. She said physicians do not always agree with dietician's recommendations and will sometimes make other recommendations. After checking PCC, she said she did not see a response from the doctor. She said she did not follow-up on her recommendations because she normally will not see a resident again for another 60-92 days unless someone at the facility alerts her that the issue has not resolved. During a telephone interview with the Dietary Manager on 11/6/2024 at 1:32pm, she said she had been employed at the facility for 4 to 5 years. She said CR#1 had a pureed diet, thickened liquids, and had to be fed. CR#1 ate in her room. She stated that the Dietician told her one time that CR#1 was not eating her food. She said it was the responsibility of the Dietician to put recommendations in place for residents when they were not eating. She said it was placed on the dietary notes. She said if a tray came back, and food was not eaten, the tray aide would notify the nurse. She did not recall being told any other time about CR#1 not eating. She said they gave her yogurt and pudding because she would eat sweets. The State Investigator asked if she was responsible for documenting residents food intake. She said, No. She said she was not feeling well, and the call ended. An interview with the Administrator on 11/6/2024 at 1:42pm, revealed he called the Dietary Manager about documentation she had concerning CR#1 meals/intake. He said the Dietary Manager was out sick, but she had documentation she kept on a Word document that she would send him today. He admitted that he did not see any nursing progress notes or plan of care notes (POC ) by the CNAs that documented refusals or her food intake. He stated that he conducted a performance improvement plan (PIP ) when he was emailed by CR#1's FM on 10/18/2024. He said after the incident the DON, dietary, housekeeping, and even therapy would be keeping an eye out to ensure every resident gets a tray and let the nurse know when they refuse. He said the CNAs or nurse might miss sometimes but others will be able to see and notify nurses on the floor when residents were not eating . He said this failure could cause residents obvious weight loss, nutritional needs not being met and not enough hydration. A telephone interview with 11/6/2024 the facility MD at 3:41pm revealed that CR#1 was losing weight and the family declined a peg tube as far as he could recall. The State Investigator asked if he had been told that the FM had found uneaten trays of food on many occasions as she was not being fed. He said he was not aware of staff being unable to feed her nor of any refusals to eat. He denied receiving any recommendations from the dietician. He stated his NP would have more information as he was at the facility weekly, and he would have to follow-up with him on this patient. He stated the protocol was to ensure there was a dietician consultant when there was weight loss for recommendations, medications, and overall patient care being addressed. He stated he could not recall any IDT meeting concerning CR#1 weight. He did not mention failure to thrive as a diagnosis that was causing CR#1's weight loss. In a subsequent interview with the MD on 11/6/2024 at 3:50pm, he stated that he had orders for supplements and the dietician recommendations were in the system. However, they were showing that CR#1 was on hospice. He said she was enrolled, and Hospice was involved in her care. He said he would have his NP reach out to me. In an interview with local Hospice representative on 11/8/2024 at 12:25pm, Rep stated CR#1 was on services from 9/13/2024-9/16/2024. In a subsequent interview with the Administrator on 11/8/2024 at 12:50pm, he stated it was the dietician's responsibility to review residents' weights weekly. He said each week she checked in on residents and when there was weight loss it should be documented in PCC. The recommendation from the dietician for CR#1 on 8/1/2024 should have been communicated to the physician or NP, they should have either approved, denied it, or made other recommendations. The orders were carried out by nursing. He said, the Dietician should have checked to see if it was approved or denied, and she could have also checked to see if the MD had ordered anything. He said when she came back the following week, she might have had to make other recommendations. He said it looked like CR#1's recommendations got missed somehow. He said the FM denied a peg tube before and after admission. He stated he can recall two occasions or meetings that was discussed with her FM that she was eating but not enough food and having weight loss. He said he was unable to find documentation for the recommendation for a peg tube. He stated that the MD had faxed him a letter which stated that CR#1 had experienced weight loss due to her dementia and failure to thrive. The State Investigator stated the MD did not mention that CR#1 had an additional diagnosis of failure to thrive, she was not admitted with this diagnosis, it was not listed on her face sheet, hospital admission paperwork, care plan, nor anywhere else. He stated, Well that is what the MD stated on the letter. He added that it was the facility's policy concerning residents that were not eating to talk to the family, offer other food alternatives, and come up with other substitutions that they were willing to eat. He said communication with the family and the physician was important. He said sometimes the MD might order different stimulants to increase their appetite or provide other medications. He stated the kitchen staff were willing to make other food for the residents. He said if staff saw CR#1 had not eaten they would have said something to the nursing staff. CR#1 was declining and a very sick resident. He said it was the family's decision not to have a peg tube placed, because she would not be able to have food by mouth . In an interview with CNA B on 11/8/2024 at 1:28 p.m., she stated she had been employed here since 2017. She was the CNA lead and central supply. She said she knew CR#1 from a previous facility. She said she was very surprised when she saw her here in July. She said she was admitted here with contractures and not walking. She said she wanted to sleep a lot. She said the FM asked her to take a picture when she ate her food and send her a picture when she worked. She said the resident ate a lot of mashed bananas, yogurt, and applesauce. She said she mentioned her weight loss to the Dietary Manager, and she said the dietician had put her on supplements. The FM bought Boost when she was admitted , but she did not recall if CR#1 drank them but she did not see any more after she was admitted . She said CR#1 ate but sometimes only 50% or less. She said she mentioned to the DON that she was losing weight. She took her weight a few times and notated the decline. She stated before she left her shift, she would always double back to see if CR#1 ate and if not try to feed her. She said she would leave the extra bottled water, thickened juice, and applesauce. In an interview with NP on 11/11/2024 at 3:26 p.m. he took out his tablet and stated CR#1 was admitted on [DATE] and on 8/1/2024. He was notified that she had poor NPO intake, so the dietician recommended house supplements, and liquid protein Juven to promote wound healing. He stated he did not see anywhere in PCC that he had placed an order or approved her recommendations. He said he was unsure of what happened. He said if there was an order, he could no longer see it in PCC. He stated he came to the facility every Monday. He also asked the nurses if anything was going on with residents that he needed to know about. No one ever told him about her severe weight loss. He stated he noticed the weight change for CR#1 upon a visit and he recommended Hospice care on 8/21/2024. The State Investigator informed him that CR#1 was taken off Hospice only a few days after being enrolled on 9/13/2024. He said he did not know she was taken off hospice. The hospice order was still active in the system, so he assumed she was still on hospice. He said when patients are on hospice services, they normally take provide life care and comfort measures. He said weight loss was usually followed up with a peg tube or hospice care. He said there was no documentation here at this facility about hospice care. He said he could see the weights in PCC, but not her food intake. He said sometimes in cases like this with severe weight loss, supplements, or a medication called Remeron or stimulant Megace, was effective but sometimes patients run into insurance not paying for it plus they cannot be on it for long periods of time due to the side effects. He stated CR#1 was put on hospice and that was why he would not see her. He said there were no nursing notes hardly and nothing mentioned about hospice being stopped. If he had been notified, he would have called the family himself and gave them the option of the medication for her appetite or a peg tube. Record review of weight monitoring policy revised on August 2024 revealed based on a resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status such as usual body weight or desirable body weight range and electrolyte balance. Guidelines: Weight can be a useful indictor of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize systemic approaches to optimize a resident's nutritional status. This process includes a. Identifying and assessing each resident's nutritional status; b. evaluating and analyzing the assessment information; c. Developing and consistently implementing pertinent approaches; d. Monitoring the effectiveness of interventions and revising them as necessary. 4. Interventions will be identified, implemented, monitored, consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. 5. A weight monitoring schedule will be developed upon admission for all residents: c. Residents with weight loss- monitor weight weekly. 7. Documentation: A. The physician should be informed of a significant change in weight and may order nutritional interventions; B. The physician should be encouraged to document the diagnosis or clinical condition that may be contributing to the weight loss; C. Meal consumption information should be recorded and may referenced by the Interdisciplinary team. E. The dietician and dietary manager should be consulted to assist with interventions; actions are recorded in the nutritional progress note. This was determined to be an Immediate Jeopardy (IJ) on 11/8/2024 at 3:18pm. The administrator was notified. The Administrator was provided with the IJ template at that time via email. The following Plan of Removal was submitted by the facility on 11/8/2024 and approved on 11/9/2024 at 5:55pm: Failure: F-692 Nutrition/Hydration status maintenance The facility failed to ensure CR#1 was monitored for weight loss resulting in a 19.7% or 17.2 lbs. in less than 3-month period. The facility failed to ensure CR#1 maintained acceptable parameters of nutritional status such as her usual body weight of 90 lbs. The facility failed to ensure CR#1 was offered sufficient fluids to maintain proper hydration. She was admitted to a local hospital severely dehydrated on 10/17/2024. 1. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. (Completion Date: 9 [DATE]) Patient CR#1 is no longer at the facility D/C 17 [DATE] All patients in the building were evaluated for weight loss. Completed by the interim DON. 6 patients are on our weight loss watchlist. Dehydration Risk Assessments have been completed. 2. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed. (Completion Date: 9 [DATE]) 3. All facility staffing policies and procedures were reviewed/revised. LNFA and the interim DON reviewed for accuracy. No changes were made. The Administrator reviewed and revised the Facility Assessment. The Facility Assessment assist Nursing facilities to conduct, document, and review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. Patient Demographics were updated. AD HOC QAPI meeting was held. Findings from AD HOC QAPI will be reported at the monthly QAA meeting for a minimum of 3 months. Staff was in-serviced on HHSC Feeding Assistant Training Manual. Staff included CNA's, MA's, Dietary, and Therapy department. Staff were trained 8-9 [DATE]. Further staff will receive training before they are allowed to work. Dietary Manager provided the training. Some of the subjects covered in the training are to observe and report any issues with the patient eating. Always report to the nurse any issues. Assist the patient as needed. If meal is refused offer an alternate meal or food from our always available menu. Meal set up always ensure water and drinks are available. Any issues with eating report it to the nurse. Any patient that is identified with an issue related to feeding or hydration will be reported to the charge nurse. The charge nurse will report to provider. It is reported using a dietary concerns form that is available at the nursing station. The form is filled out with the issue and given to the nurse. The nurse reports the issue to the provider. Additionally, in the MAR there is an order that the nurse chart for each meal the amount of the meal that was consumed. This is audited QD by the interim DON/designee. If no action has been taken the interim DON/designee will contact the provider and the RD. Patients that are on the watchlist have monitoring in the MAR for the nurse to chart the amount of their meal consumed. MAR is reviewed/monitored QD by interim Don/Designee. MD informed of the monitoring. interim Don/Designee will update care plans and the MARS. All patients on the Watchlist can be identified by the tray ticket it will be noted Watchlist. When the weekly weights are taken any patient that flags will be reviewed by interim Don/Designee and RD and added to the watchlist. interim Don/Designee will add to MARS. If the patient flags for weight loss, they are placed on weekly weights. The interim Don/Designee will provide the list to the Director of Rehab and the weights will be taken by the therapy department. The scale is calibrated Q 3 months or if a discrepancy is detected . Dietician's recommendations will be sent to the interim Don/Designee and the LNFA/Designee. This will ensure that interim Don/Designee and the LNFA/Designee know when they were received and forwarded to the Provider. Dietician's recommendations will be sent to the providers to be approved or denied. interim Don/Designee will implement the orders and notify the Dietician if they have been approved or denied. This process to be completed in no more than 72 hours. Dietician was notified of the watchlist 8 [DATE]. Dietician has reviewed them, and recommendations/progress notes received. interim Don/Designee and dietary manager will be trained by the LNFA. Monitoring of the Plan of Removal Included: Record review of a list of residents on the watchlist for weight loss and risk of dehydration included (6 Residents): Residents #2, 3, 4, 5, 6 and 7) were listed. Record review of their records in PCC revealed that risk assessments for weight loss had been conducted and weekly weights were ordered. In addition, dehydration risk assessments were completed for all 6 residents and fluid intake was ordered to be entered into PCC. Monitoring input of food and hydration was on their MARS. Record review of the facility's assessment tool dated 5/9/2024 revealed resident characteristics of weight management was added. Record review of the facility's food intake form had questions about whether there were concerns about resident nutrition intake, hydration intake, and staff were to enter the answer yes or no, indicate the name and room number of the resident, staff name, and explain the concern. Record review of scale calibration from the local company revealed that the scale calibrations were done monthly, and the scale showed a .02 lbs. error rate on 11/13/2024. Record review of Ad Hoc QAPI meeting sign-in sheet dated 11/9/2024 revealed the MD, the Administrator, and the SSD met concerning the Immediate Jeopardy. Record review of sign-in sheets for the following training: HHSC feeding assistant training manual was conducted by the Dietary manger on 11/8-11/9/2024. Interviews with the Director of Therapy, and OT therapist revealed on 11/12/2024 they have been trained on notifying a nurse if a resident was not eating or if they notice a tray with uneaten food, they were assisting with feeding residents, and were responsible for weighing the resident weekly. Interviews with RN A and C, CNAs A, B, D, housekeeping A, CMA's A and B between 11/10/2024-11/11/2024 from the morning shift nurses (6a-6p), and CNAs and MA's (6a-2pm) shifts all were able to describe their recent training on feeding assistance, documentation of food and hydration intake, notifying the nurse, physician, family and dietician, and completing the form if there were concerns about weight and hydration. Interviews between 11/11/2024-11/13/2024 were conducted with the RN consultant and revealed her to state she provided in-services for all nursing staff on feeding the residents, ensuring they document weight loss, food intake, take weights weekly for residents identified as at risk or on the watchlist, documenting all additional residents that should be added to the watchlist, consulting with the physicians, families, and dietician as needed. She said the new DON will follow-up with physicians, dietician, and families. Other interviews were with the evening and overnight staff including LVN A, LVN B, and CNA E. They were all able to explain their new process of notifying nursing about concerns with residents not eating or drinking adequate liquids utilizing the form provided, adequate documentation of the amount of intake, documenting notifications to the physicians and families via nursin [TRU

Based on record review and interview the facility failed to ensure an accurate MDS assessment to reflect the resident's status for 1 of 5 (CR#1) reviewed for MDS assessment accuracy. -The facility failed to ensure CR#1's MDS was updated to accurately reflect her significant change in her weight. This failure placed residents at risk of not receiving care and services to meet the needs of the residents. Findings Included: Record review of CR #'s face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Alzheimer Disease (a progressive disease that destroys memory), cognitive communication deficit (a difficult with communication that is caused by a disruption in cognition), prediabetes, and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of CR#1's admission MDS dated [DATE] revealed: Section C500 -Brief interview of mental status was unscored. Section GG - Functional Abilities and Goals reflected: A. Eating, oral hygiene, toileting, showers, upper and lower body dressing all were coded as 01 (dependent-helper does all the effort). Section K- Swallowing/Nutritional Status revealed Swallowing Disorder was marked as Z. None of the above (loss of liquids, holding food in mouth, coughing, choking, or complaints of difficulty or pain with swallowing). Section I- Nutritional status 152600- Malnutrition had no entry or X for malnutrition risk. Record review revealed no significant change MDS was provided when CR#1 weight went from 87.2 lbs on 7/29/2024 to 71.6 lbs. on 8/28/2024. Record review of CR#1's discharge MDS dated [DATE] indicated Section GG- Functional abilities had a code change of (2)- which indicated the CR#1 required substantial or maximum assistance to eat (helper does more than half the effort). Section K- Swallowing/Nutrition indicated: Weight Loss was coded (2)- Yes, not on physician prescribed weight loss regiment. Section I- Nutritional status 152600- Malnutrition had no entry or X for malnutrition risk. Record review of CR#1's care plan dated 7/31/2024 and revised on 8/2/2024 reflected: CR#1 had a nutritional problem or potential nutritional problem r/t mechanically altered diet, Alzheimer disease, and prediabetes. Goal: CR#1 will maintain adequate nutritional and hydration status weight stable, no signs and symptoms of malnutrition or dehydration through review date of 11/9/2024. Interventions: Administer medications as ordered, monitor and document for side effects of effectiveness. Monitor/document/report PRN any signs and symptoms of dehydration. Monitor/record/report to MD PRN signs and symptoms of malnutrition: Emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months and >10% in 6 months. Record review of weight summary report revealed: 7/29/2024- CR #1 was 87.2 lbs. 8/28/2024- 71.6 lbs. 9/11/2024 - 75.6 lbs. 9/18/2024- 73.8 lbs. 10/7/2024- 70.0 lbs. During an interview with CR#1's FM on 11/1/2024 at 3:20 p.m. the FM said the facility was responsible for feeding CR#1 but every 2- or 3-days the FM came to visit, and she always asked about food that was still sitting on her table. She said the uneaten food sat well past the mealtimes such as 1 hour after breakfast and sometimes a couple of hours after lunch. She said when she spoke with the CNAs and the nurses, she was told that she had substitutions, but did eat. The FM said she would try to get to the facility for her mealtimes just to observe, but the last few weeks she was unable to get there due to some personal issues. The FM said she took care of CR#1 for [AGE] years and she knew that she would eat if she had to help with the feedings that the facility said they would provide. The FM said staff were supposed to feed her as she was dependent. CR#1 could not feed herself. She stated when she arrived at the facility on 10/17/2024 and saw CR#1's food sitting on her table uneaten. She said staff were mingling near the breakroom so she got very angry and dialed 911 to have her mother sent to the hospital. She said when she was admitted at the local hospital, she was 50 lbs. She said she was severely malnourished and dehydrated. She said she did not recall having more than one care plan meeting, but she mostly called and spoke with the DON or the SSD about her weight. She said she was unaware if the facility had done another care plan to address the weight loss. An interview with the SSD on 11/6/2024 at 10:03am, revealed her to state she had been employed at the facility for 2 years. She said she had been in contact with the family of CR#1. She said she had personally reported to the DON several times that they were concerned about the resident not eating. She said CR#1's FM had been concerned and she witnessed a call between FM and the former DON about placing a peg tube so the resident would get food. She said the former DON questioned the FM about placing her on hospice instead of a peg tube. She said as far she knew the FM was looking into her options of hospice companies around September 2024 sometime. She said the care plan meeting notes she found in PCC was held on 8/8/24 and the FM was not able to attend. She stated care plan meetings are quarterly unless there is a change in condition. She said she does not know why they would not have had another care plan meeting when CR#1 began to lose weight. An interview with the Dietician on 11/6/2024 at 11:45am she said she does rounds at the facility every Thursday. She said after she put in her recommendations for the MD she had to wait on an approval. She said she was not permitted to write any orders. All orders must come from the MD. She said she input recommendations for CR#1 in August 2024. She said she also sent the MD a letter which notified him that she had recommendations that he needed to approve. She said physicians do not always agree with dietician's recommendations and will sometimes make other recommendations. After checking PCC, she said she did not see a response from the doctor. She said she did not follow-up on her recommendation because she normally will not see a resident again for another 60-90 days unless someone at the facility alerts her that an issue has not resolved. An interview on 11/6/2024 at 1:10pm, MDS nurse stated she had been employed since January 2024. She stated she was not aware of CR#1's weight loss prior to her discharge. She stated the MDS assessments were to be completed when a resident was admitted , quarterly, and if there was a discharge. She said she worked remotely and would have to be told by the clinical staff about any changes. She said she would go over the 24-hour report every day. She stated CR #1's weight loss was not noted on the 24-hour report. She said she would not necessarily know about significant changes occurred unless someone bought it to her attention because she was not in the building every day. No one notified her that CR#1 had weight loss. She said the DON would have known about it. She stated the recent update to CR#1's discharge MDS was completed on 10/21/2024. She said she entered the updated information because she assumed she would have returned to the facility. She said she would not have done any updates to the MDS if she knew CR#1 was not returning to the facility . An interview with the Administrator on 11/8/2024 at 12:50pm, he stated it was the dietician's responsibility to review residents' weights weekly. He said each week she checked in on the residents and when there was weight loss it should be documented in PCC and then it was the MDS nurses' responsibility to ensure that the MDS and care plans were updated. He said he was not sure why a significant change MDS was not updated. Record review of the facility's change in condition policy revised in February 2021 stated it is the facility's policy to promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 9. If a significant change in the resident's physical condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction manual. Record review of MDS Nurse job description revealed the position summary: Responsible for the coordination, scheduling and submitted of the resident's clinical assessments Minimum Data Set (MDS) as required by state and federal regulations as well as other third-party payers. This position reports to the DON.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. -The door to the medication room was not always closed . -Expired medication (gentamicin IV) in the medication fridge (expiration date 03/29/2024). -Expired gastrostomy feedings (Glucerna 1.5 cal) 7 bottles in the medication room (expiration date June 1st 2024). This deficiency placed the NF at risk for possible drug diversion and residents who received gastrostomy feedings at risk for gastrointestinal complications and decrease quality of life. The findings included: Record review of CR #1 face sheet dated 8/01/2024 revealed a[AGE] year-old- male admitted to the NF on 03/27/2024. CR #1's diagnoses included the following: myopathies (disease of the muscle), pressure ulcer of the sacral (located below the lower back and above he tailbone), end stage renal (kidney) disease, heart disease, and local infection of the skin. Record review of CR #1's Admission MDS dated [DATE] revealed that CR #1 had a BIMS score of 15 indicating CR #1's cognition was intact. Further review of section O (special treatments) revealed that CR #1 was coded as receiving IV antibiotics. Record review of CR #1's comprehensive care plan dated 03/28/2024 revised 04/04/2024 revealed that CR #1 was being care planned for receiving antibiotic therapy related to a sacral wound with an intervention that included administering antibiotics as ordered. Record review of CR #1's Physician Orders reflected the following: -Dated 03/28/2024 gentamicin sulfate one time a day every Monday, Wednesday, and Friday for wound infection give 1.5mg/kg IV piggy bag post HD on Monday, Tuesday, and Friday. -Dated 06/25/2024 may discharge home with home health, skilled nursing, PT, OT, DME rolling walker. Record review of CR #1's MAR for June 2024 and July 2024 did not reveal that CR #1's was administered the medication gentamicin IV. Record review of CR #1's Discharge Summary revealed that CR #1 discharged from the NF on 07/03/2024. Observation on 07/30/2024 at 10:32AM the door to the medication room was open. Further observation was made of a trash can up against the door. In an interview on 07/30/2024 at 10:32AM with RN A, she said the door to the medication room should always be closed to prevent someone from taking medications out of the medication room who did not have authorization. RN A closed the door to the medication room. Observation on 07/30/2024 at 10:42AM of the medication room fridge was a 100ml bag of normal saline. The bag was labeled with CR #1's name reading gentamicin 140mg. The expiration on the bag was 03/29/2024. Further observation inside the bottom drawer of the fridge was two clear plastic containers with food inside of them. Further observation was made in the medication room sitting on top of the counter were7 bottles of gastrostomy feedings labeled Glucerna 1.5 cal 22.8 fld oz . The expiration on the bottles read June 1st, 2024. In an interview on 07/30/2024 at 10:45 AM with RN A, she said food should not be placed inside of the fridge in the medication room but inside of the fridge in the employee break room. RN A said everyone should be checking the medication room for any expired medications. RN A said the NF had one medication room. RN A said CR #1 had discharged from the NF . Observation on 07/31/2024 at 8:37AM the door to the medication room was wide open while RN B was sitting at the nurse's station. Observation on 07/31/2024 at 8:45AM of the DON standing in the hallway by the nurse's station. The door to the medication room remained open. The DON walked away from the nurse's station toward hall 100. Observation on 07/31/2024 at 8:50AM the door to the medication room remained open with RN B sitting at the nurse's station on the computer. RN B then left the nurse's station walking down Hall 200. There was no one at the nurse's station. There was a sign on the medication door reading Nurses and medication aides allowed only!!! Door must remain closed at all times. In an interview on 07/31/2024 at 9:37AM with RN B, she said she had been working at the NF for almost 6 months, full time 6am-6pm. RN B said the door to the medication room was supposed to be closed at all times to prevent someone who was unauthorized from entering into the medication room. RN B said it must have been an oversite on her part to leave the door open. In an interview on 07/31/2024 at 10:05AM with the DON, she said the door to the medication room should be closed at all times because of medications being inside of the room. The DON said the medication room had a machine called a Nexis inside of the room that housed medications that included narcotics. The DON said in order to access the Nexis one had to be given a log in with a password. The DON said it was herself and the nurses on the unit that were supposed to check the medication room for any expired medications or feedings. The DON said no food was supposed to be stored inside the fridge in the medication room for sanitation and infection control reasons. The DON said it must have been the nurses on the night shift that had done this . In an interview on 08/01/2024 at 1:58PM with the pharmacist via phone, she said when she came to the NF. Her job duties included the following: drug regimen reviews, drug destruction, and checking for any expired medications. The pharmacist said she was last at the facility in July of 2024. The pharmacist said it was important to check for expired medications to promote safety for the residents. Record review of the NF policy on Medication Storage with a copy right 2024 revealed in part: .t is the policy of this facility to ensure all medications housed on the premises will be stored in the pharmacy and /or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, and ventilation .only authorized personnel will have access to the keys to locked compartments .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were dated as opened/preparation discarded after 96 hours. 3. The facility failed to keep food off the floor. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on [DATE] at 8:15 AM revealed the following. 1. 2 Quarts of High Protein Supplement Drink in the walk-in cooler with a manufacturer expiration date of [DATE]. 2. A Plastic container of Chocolate Pudding in the walk-in cooler with a used by date [DATE]. 3. A Plastic container of Cream of Mushroom Soup in the walk-in cooler with a used by date [DATE] 4. A Plastic container of Chicken Gravy in the walk-in cooler with a used by date [DATE] 5. A Plastic container of Spaghetti Sauce in the walk-in cooler with a used by date [DATE] 6. 2 cs. of Frozen Orange Juice in the walk-in freezer stored on the floor. 7. 1cs. Of frozen Okra in the walk-in freezer stored on the floor. In an interview with the Dietary Food Service Manager on [DATE] at 10:25 AM; she stated the leftover food stored in the refrigerator should have been used or discarded prior to the use by date; she stated that the Cases of food should be off the floor. She said that she would be re-in-service dietary staff on labeling and dating the food. She said that the tray aides were responsible for checking the food in the cooler/freezer and to discard food prior to the used by date. Record review of the facility's policies and procedures for Food Safety dated ,d+[DATE] read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 96 hours unless otherwise indicated. For food storage keep off floor.

Based on observation, interview, and record review the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: - The facility failed to label and date food stored in the dry goods storage, refrigerator, and deep freezer. - There were chemicals stored (by the 3-compartment sink) in an open area in the kitchen. - The kitchen staff did not change gloves when changing tasks. - The staff did not wash their hands upon entering the kitchen and they did not wash hands properly. - The kitchen staff did not use the red sanitizing bucket to wipe down preparation countertops during food prep and meal service. - The kitchen staff failed to wear hairnets properly while working or entering the facility's kitchen. These failures could place all residents who eat food served by the kitchen at risk of cross contamination and food-borne illness. Findings Included: During observation and interview on 05/21/23 beginning at 08:15 am during a walk-through of the kitchen accompanied by the cook revealed the following: Refrigerator : - Dirty onion peels on the floor. - 16 ounce of hamburger buns not sealed properly. - 24-12-ounce bags of tortillas outside of the original box dated 5/18/23 not labeled. - 5 wrap tortillas out-side of the original box not dated and not labeled. Deep Freezer: - The bottom of the freezer had frozen dirty ice particles. The cook said the freezer had not been cleaned in seven months. - 5lb chicken dated and not labeled. - 16-ounce bag of French fries outside of the original box not labeled. - 4 mini pancakes not dated and not labeled. - 16 ounces of cookie dough not dated and not labeled. Dry Pantry: - 2 Dented cans stored with undented cans 106 ounces of chicken noodle, 106 ounces of sliced pears). - Barbecue sauce stored with overflow of sauce leaking out at the top of the lid. - 1-32 ounce of [NAME] food coloring rim and outside of the bottle was sticky with food coloring drippings. - 40lb bin with thickener not sealed properly. The Cook said the thickener not sealed properly expose the thickener to cross contamination. Observation and interview on 5/21/23 at 8:15am accompanied by the Cook revealed a 1-gallon bag of disposable napkins not sealed stored under a preparation countertop. There were 20 Bananas in a storage container stored next to pots, pans, and bowls under neat a preparation countertop. There were chemicals (polish Ecolab, medallion steel cleaner and polish, oven, and grill cleaner aerosol 20oz) stored next to pots and pans. The Cook said the chemicals should be stored in the chemical closet to prevent cross contamination. There were cooking pots, pans, ladles and serving spoons hanging off a cooking rack located near kitchen air vents. Observation and interview on 5/21/23 at 8:45am with the Dishwasher revealed the dishwasher took a blue cloth from an open box (underneath a preparation countertop located by the air vent covered with cake dust) to wipe the dishes dry. She looked up at the vent in the kitchen and said it look like mildew or something fuzzy hanging from the vent. Observation and interview on 05/22/23 at 10:46am revealed the Cook took bell peppers out of the bin slicing, cutting to prepare for the frying pan. She touched the dirty dishes and returned to touch the bell peppers. She said she did not wash the peppers before slicing and cutting them. She picked up the bell peppers and mixed them in with the cooked beef patties off to the right side of the same container. She said she needed more space, so she placed the bell peppers in the same container with the beef patties. She said there are some residents who do not like bell peppers. The Cook removed the temperature gauge from the ice water (the ice water had food particles inside the glass) and placed it into the vegetables without cleaning it with an alcohol wipe; the gauge was in the ice water; the cook placed the temperature gauge into the pureed food used the same alcohol pad and placed it into the ice glass of water. The Cook poured the glass of ice water out of the container, but she did not wash the glass she added ice and water to the glass and continued using the temperature gauge to check the temperatures of the food. During an interview on 5/23/23 at 11:41am, the Dietician Manger/ Activity Director, said she is the Dietary Manager over the kitchen. She said every morning she does her walk-in inspections, daily inventory, audit food, check items dated and labeled. She said the dented cans should go outside of the storage room or in her office until she returns them to the food company. She said the refrigerator, the standup freezer and the deep freezer should be clean. She said everything should be dated and labeled. She said nothing should be upside down and nothing should be left opened and turned in different directions. She said all boxes should be closed, dated with the name placed on the box faced in the direction that is readable. She said all the seasoning should be wiped down individually after each use. She said all the individual seasoning should be dated properly and facing toward the front. She said the chemicals are to stay in the storage area. She said no food should be out in the open while using chemicals. She said the staff had an in-service on hand washing and infection control April 2023. During an interview on 5/23/23 at 2:00pm, the Administrator, he said he walked through the kitchen and made changes where he saw there was a need. He said he checked to make sure items are dated. He said he would eat from the kitchen to check the quality and the temperature. He said the chemicals should not be in the open area where the food is stored. He said if the food temperatures are not correct for the residents' pathogens can enter the food. There were two G-tube feeding at the facility. Record review of the facility's policy titled: Routine Cleaning and Disinfection : It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Record review of the Facility's policy titled: Routine Cleaning and Disinfection : Hand Hygiene read in part .hand washing, antiseptic hand wash and alcohol-based hand rubs. Record review of the Facility In-Service Training Report on Infection Control and Handwashing dated 4/18/2023 revealed: Nursing, Housekeeping, and Dietary presented for training. According to the FDA Food Code 2022 dated January 18, 2023 Chapter 3: Food: 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD According to the FDA Food Code 2022 dated January 18, 2023 Chapter 3: Food: 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. According to the FDA Food Code 2022 dated January 18, 2023 Chapter 2: Management and Personnel: .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: read in part .(E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; read in part .H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to ensure 3 residents (Resident #7, Resident #16, and Resident #14) of 15 residents reviewed for accidents and supervision had an environment that was as free of accident hazards as possible. -Residents #7 and #16 were at risk for falls. The facility failed to consistently place fall mats next to their beds when the residents were occupying the bed. -Resident #14 was at risk for falls. The facility created an injury hazard by placing the resident's bed table in the pathway of a potential fall. These deficient practices could place residents at risk for injury. Findings Include: Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was Dementia. Record review of Resident #7's quarterly MDS dated [DATE] revealed the resident had both short and long-term memory deficits and was cognitively severely impaired. The resident required extensive assistance with one-person assist with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS reflected the resident did not demonstrate steady balance without the assistance of staff during transfers. The MDS reflected Resident #7 exhibited impaired range of motion to all extremities. Section O: Special Treatments noted Resident #7 was on hospice. Record review of Resident #7's Care Plan initiated on 06/01/21 and revised on 4/24/23 read in part . Dementia, Fatigue, Limited Mobility, weakness, Date Initiated: 06/01/2022, Revision on: 09/20/2022. Target Date: 08/21/2023. Bed Mobility: The Resident required extensive assistance with one-person assist for repositioning in bed. Revision on: 06/18/2022. Bedfast: The Resident was bedfast all the time. Problem: At risk for falls r/t confusion. Goal: will be free of falls. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Fall mat on floor at bedside. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Follow facility fall protocol . Observation and interview on 5/21/23 at 9:15 am revealed Resident #7 lying in bed asleep. There was a floor mat by her bedside to her left. There was a floor mat standing against the wall to the right corner next to the window as you entered the resident's room. Observation on 5/21/23 at 12:20 pm revealed Resident #7 in bed asleep. There was no floor mat by her bedside. RN A said Resident #7 was a fall risk and she required floor mats (on both sides) by bedside while the resident was in bed and her bed had to be at the lowest position. She said it was the CNAs responsibility to ensure fall risks residents had their fall mats by their bedside while residents were in bed. She said the fall mat was meant to cushion the resident's fall. She could not recall the last-time she was in-serviced for fall prevention. She said the resident could fall and get injured if their fall mats were not placed by their bedside while in bed. Resident #16 Record review of Resident #16's face sheet revealed a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Her diagnosis was history of falls. Record review of Resident #16's quarterly MDS dated [DATE] revealed the resident had a BIMS of 99 indicating the resident was unable to complete the interview. The resident had both short and long-term memory deficits, and she was cognitively severely impaired. The resident required extensive assist of two persons bed mobility. She required extensive assist of one person for transfers, dressing, eating, toileting, and personal hygiene. Record review of Resident #16's Care Plan revised on 02/17/2023 read in part . Focus: Resident #16 had an actual fall on 3/2/22--Fall--without injury; 8/19/22 - Fall with injury, date Initiated: 03/03/2022; Revision on: 02/17/2023. Goal: Resident #16 will resume usual activities without further incident through the review date, revision on: 03/11/2022, Target Date: 05/20/2023. 2 staff assist during showers, revision on: 08/23/2022, 8/19/22: Send to ER for eval and treatment as indicated. For no apparent acute injury, determine and address causative factors of the fall. Monitor/document /report PRN x 72h to MD for signs/symptoms: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation . Observation on 5/12/23 at 9:05 am revealed Resident #16 had mucus on her right eye. She was sitting in her wheelchair. She was making facial and hand gestures. This Surveyor pushed her call light. CNA DD came into the room and said the resident wanted to be transferred to her bed. CNA DD she made facial and hand gestures when she wanted to be transferred to bed because she was nonverbal. There was a floor mat standing against the wall to the left corner as you entered the resident's room. Observation on 5/12/23 at 11:00 am revealed Resident #16 lying in bed asleep. She did not have her floor mat by her bedside. The resident's floor mat was standing against the wall to the left corner as you entered the resident's room. Observation and interview on 5/12/23 at 11:55 am revealed Resident #16 lying in bed asleep. She did not have her floor mats by her bedside. RN A said Resident #16 was a fall risk because she had had about 3 falls in the past. She said CNAs were responsible for ensuring floor mats for fall risk residents were in place and their beds were lowered to the lowest position when residents were lying in their beds . She said the purpose of the floor mats was to cushion the resident's fall to prevent injury. She said CNA DD was supposed to place the resident's floor mat by her bedside when she laid her to bed. She said the charge nurse was responsible for ensuring CNAs were placing fall mats by resident's bedside while they were in bed. She said she could not remember the last time staff were in-serviced for fall prevention interventions. Resident #14 Record review of Resident #14's face sheet revealed an [AGE] year-old female who was admitted on [DATE]. Her diagnosis was Dementia. Record review of Resident #14's quarterly MDS dated [DATE] revealed the resident had a BIMS of 7 out of 15 indicating the resident was cognitively severely impaired. The resident required extensive assistant with two-person assist for bed mobility and transfers. She required extensive assistance with one person assist for dressing, eating, toileting, and personal hygiene. The MDS reflected the resident did not demonstrate steady balance without the assistance of staff during transfers. The MDS reflected Resident #14 exhibited impaired range of motion to one lower extremity. Record review of Resident #14's Care Plan revised on 5/21/23 revealed the resident was not care planned for falls or fall mats by her bedside . Observation on 5/21/23 at 9:10 am revealed Resident #14 spending time with her family. She was lying in bed. There were no fall mats by her bedside. There was a square 3X3 flat cushion in front of the resident's bedside dresser. There was a fall mat standing against the wall to the left corner next to the window as you entered the resident's room. The resident's bed was raised. Observation and interview on 5/21/23 at 9:45 am revealed a CNA A enter the room with this Surveyor. The CNA A said Resident #14 was a fall risk and she was care planned to have fall mats by her bedside on both sides . She said she should have placed the resident fall mats by her bedside when the resident was in bed. She said the purpose of the fall mats was to cushion the resident's fall. She said the square 3X3 flat cushion in front of the resident's bedside dresser was not a fall mat. She said she did not know how it got there. CNA took the fall mat standing against the wall and placed it by resident's bedside. She said the resident's bed was at the lowest position. This Surveyor asked to assess it. CNA cranked the turning knob, and the bed was lowered to the lowest position after Surveyor intervention. Observation and interview on 5/21/23 at 12:20 pm revealed Resident #14 lying in bed asleep. She had fall mats by her bedside on both sides. There was a rolling table on top of the fall mat by resident's right side of the bed facing the window. RN A said Resident #14 was a fall risk and she required fall mats and her bed lowered to the lowest position. She said it was the CNAs responsibility to ensure fall risks residents had their fall mats by their bedside while residents were in bed. She said the rolling table should not have been placed on top of the fall mat because if the resident fell on that side, it could cause the resident injury. She said she could not recall when staff were in-serviced for fall prevention interventions. In an interview on 5/21/23 at 1:34 pm with the DON, she said she started working at the facility about 6 weeks ago. She said the Therapists assessed residents for fall risk and notified the MDS nurse so residents could be re-assessed, and care planned for fall risks. The DON said the MDS nurse notified the family if they became fall risk. She said fall mats and placing beds in the lowest position were used as interventions to prevent future falls. She said the CNAs were responsible for placing fall mats by resident's bedside while residents were in bed. She said the risk to residents when fall mats were not in place was injury. She said she could not recall the last time she in-serviced staff for fall prevention interventions. She said she had oversight to ensure nursing staff were following fall risk protocols. Record review of the facility's policy titled: Accidents and Supervision not dated read in part . 1. identifying hazards and risk. 2. evaluating and analyzing hazards and risk. 3. implementing interventions to reduce hazard and risk. 4. Monitoring for effectiveness and modifying interventions when necessary. Implementation of interventions: H. Facility-based interventions may include but are not limited to i. Educating staff. ii. repairing the device/equipment. 4. Monitoring and modification-monitoring: Monitoring and modification processes include: a. ensuring the interventions are implemented correctly. b. evaluating the effectiveness of interventions a. d. evaluating the effectiveness of new interventions. 5. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents . Record review of the facility's policy titled: Fall Prevention Program not dated read in part . High Risk: Implement universal environmental interventions to decrease the risk of resident falling, including, but not limited to: a clear pathway to the bathroom and bedroom doors. Bed is locked and lowered to a level that allows the residence. Feet to be flat on the floor when the resident is sitting on the edge of the bed. Call light and frequently used items are within reach. Adequate lighting. Wheelchairs and assistive devices are in good repair. Implement routine rounding schedule. Monitor for changes in residence cognition, gait, ability to rise, or sit, and balance. Encourage residence to wear shoes or slippers with nonslip soles when ambulating. Ensure eyeglasses, if applicable, are clean, and the resident wears them when ambulating. Monitor vital signs in accordance with facility policy. High risk protocols: the resident will be placed on the facilities fall prevention program. Indicate fall risk on care plan. Low/Moderate Risk: Interventions, including, but not limited to: assistive devices, increased frequency of Brown's, sitter, if indicated, medication regimen review, a little bit, alternate, call, system, access, scheduled, ambulation or toileting, assistance, family and caregiver or resident, education, and therapy services referral .

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #30) of 1 resident reviewed for respiratory care. -Resident #30's oxygen nasal cannula tubing was dated 2/12 and not stored properly when not in use. -Resident #30's nebulizer mask and tubing were not dated and not stored properly when not in use. This these deficient practices could place residents receiving respiratory care at risk for respiratory infection leading to pneumonia. Findings Include: Record review of Resident 30#'s face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and Asthma. Record review of Resident #30's quarterly MDS dated [DATE] revealed the resident had a BIMS of 12 out of 15 indicating the resident had moderate cognitive impairment. The MDS reflected additional diagnoses of acute respiratory failure and septicemia (systemic infection). Record review of Resident 30#'s Care Plan revised on 01/30/2023 read in part . Resident #30 has altered respiratory status/difficulty breathing r/t acute respiratory failure, COVID-19, pneumonia, and COPD, pleural effusion (excess fluid buildup around the lungs). Goal: Resident #30 will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date . The section 'interventions' did not address the nebulizer or the oxygen tubing. Observation and interview on 5/21/23 at 9:50 am revealed Resident #30 lying in bed eating breakfast. There was a nebulizer on top of her dresser drawer by her bedside. The tubing (not dated) to the nebulizer was inside the first drawer with the mouthpiece laying on stacks of paper documents, a creme lotion bottle, and other personal items. There was a nasal cannula with the tubing dated 2/12. Neither the tubing's nor the mouthpiece were bagged while not in use. There was a Ziplock bag in the drawer with no date on the bag. The Resident said staff stored the tubing and mouthpiece in the first drawer. She said the dresser drawer by her bedside was beyond her reach. She said she received breathing treatments for COPD. She said she had been using oxygen more frequently after she recently moved out of room [ROOM NUMBER] because it had mold. In an interview on 5/21/23 at 12:40 pm with RN A, she said tubing to oxygen or nebulizer treatments should be changed every 48 hours. She said the tubing, nasal cannulas, and mouthpiece should be dated and stored in a Ziplock bag while not in use. She said the Ziplock bag should be dated as well. She said Resident #30 was receiving oxygen PRN at 1.0 milliliters for congestive heart failure. She said the nursing staff was monitoring her saturation and the resident could verbalize feeling shortness of breath. She said she noticed the resident was requesting oxygen more frequently since she moved from room [ROOM NUMBER] last week. She said she was unsure of what the facility's policy was for changing and dating tubing's because she had only been at the facility for six weeks. She said the respiratory therapist changed the tubing's throughout the facility. She said she did not know who left resident #20's tubing's and mouthpiece in drawer not properly bagged while not in use . She said the risk to residents was cross-contamination leading to infection. She could not recall the last time she was in-serviced for infection control or dating and storing tubing's and mouthpieces for pulmonary associated treatments. In an interview on 5/21/23 at 12:55 pm with Respiratory Therapist, she said she had been at the facility for 6 weeks as PRN. She said she worked one day per week (Sundays) between 8 to 12 hours. She said she was responsible for changing resident's tubing's, nasal cannula, and mouthpiece weekly on Sundays. She said the tubing should be dated and stored in a Ziplock while not in use to prevent cross-contamination leading to infection. She said she was in-serviced upon her hired date six weeks ago. She said she did not know how the failure occurred because she changed the resident tubing on Sunday, 5/14/23 so someone came behind her to change it and mistakenly place a date of 2/12. In an interview on 5/21/23 at 1:17 pm with the DON, she said the past Respiratory Director could have been the person who changed the oxygen tubing for Resident #30. She said the resident had PRN orders for oxygen. She said she was on 2.0 liters about 6 weeks ago when she started. She said residents that needed nasal cannula or nebulizer mouthpieces and tubing upon admission was set up by the Respiratory Therapist and it was their responsibility for dating the nebulizer masks and tubing and nasal cannula tubing's and humidifiers upon set up. She said the nebulizer mouthpiece and nasal cannula tubing was placed in resident's bedside table in the first drawer and should be stored in a closed Ziplock bag. She said the bag had to be dated as well. She said the purpose for dating Ziplock bags, nebulizer tubing's, masks, and nasal cannula tubing's was for respiratory staff to know when to change them out. She said residents could get infection when they were not changed out. She said she could not recall the last time staff were in-serviced. She said the Respiratory Director would have oversight, but he was no longer employed with the facility since 5/18/23. She said she had oversight during the transition of hiring a new Respiratory Director. Observation and interview on 5/22/23 at 6:25 am revealed Resident #30 lying in bed watching TV receiving 2.5 milliliters of oxygen infusion. There was a nebulizer on top of her dresser drawer by her bedside. The tubing (not dated) to the nebulizer was inside the first drawer with the mouthpiece laying on stacks of paper documents, a creme lotion bottle, and other personal items. There was a nasal cannula with the tubing not dated. Neither the tubing's nor the mouthpiece were bagged while not in use. There was a Ziplock bag in the drawer with no date on the bag. The Resident said staff changed the oxygen tubing yesterday (5/21/23). She said she could not recall the last time it was changed. She said she has been telling the nursing staff that she was needing oxygen more frequently since she moved out of room [ROOM NUMBER] last week due to the mold. Record review of the facility's policy titled: Nebulizer Therapy not dated read in part . Care of equipment . 1. Clean after each use. Disassemble parts after every treatment. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5 shake off excess water. 6 Air dry. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a Ziplock bag. 8 Change nebulizer tubing every seven days or PRN. Date tubing or bag. 9. Periodically disinfect unit .

Based on interview and record review the facility failed to ensure a post-discharge plan of care was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment and the post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services for 1 of 2 residents (CR # 1) reviewed for an effective discharge process. The facility failed to complete a discharge summary prior to CR#1's discharged . This failure could place residents at risk for incorrect, incomplete, or misleading information recorded regarding discharged or deceased residents and failure in the continuity of care for residents. Findings include: Record review of the, undated, admission sheet for CR # 1 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses included essential (primary) hypertension (a condition in which the blood vessels have persistently raised pressure), Paroxysmal atrial fibrillation (an irregular heart rhythm) and hyperlipidemia (an elevated level of lipids in blood). Record review of CR#1's electronic medical record revealed there was no discharge MDS. Record review of CR#1's electronic medical record revealed the discharge summary dated [DATE] was incomplete. In an interview on [DATE] at 1:56p.m., with the DON, she said the discharge summary was needed to show the care the resident received while in the facility and that measures were put in place for continuity of care. She said the Social Worker was responsible for completing the discharge summary. She said the discharge summary should have been completed upon discharge. So, everyone would know why the patient was discharged . In a telephone interview on [DATE] at 11:44a.m., with Social Worker Supervisor, she said the facility had a social worker designee due to low census. She said the designee was responsible for starting and completing the discharge summary upon resident's discharge. She said it was important to have discharge summary to make sure residents needs were met prior to discharge. Record review and interview on [DATE] at 12:32p.m., with Social Services Designee, she said the SW Supervisor brought it to her attention this morning that CR#1's discharge summary was incomplete. She said she started discharge summary on admission and worked on it thought out the resident's stay. She said the discharge summary should be completed 72 hours after discharge. She said it was important to complet the discharge summary to know when and where the resident went and things they needed. Record review of facility's Discharge Summary (not dated) revealed read in part: .Policy: It is the policy of this facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies .

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #20) of 1 resident reviewed for enteral nutrition. -Resident #20 was receiving enteral nutrition via a G-tube. The closed-system formula bag was not labelled with the start time. The deficient practice placed residents who require enteral nutrition at risk for complications including infection if the formula bag was not replaced within a safe timeframe. Findings Include: Record review of Resident #20's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was dysphagia, oropharyngeal phase (difficulty swallowing). Record review of Resident #20's quarterly MDS dated [DATE] revealed the resident had both short and long-term memory deficits and had severely impaired cognition. The resident required two-person assistance with bed mobility and extensive assistance from one person for eating and transfers. The MDS reflected the resident had a gastrostomy (feeding) tube (G-tube). Record review of Resident #20's Care Plan revised on 05/21/2023 read in part . Resident #20 insertion site will be free of signs and symptoms of infection through the review date . The Care Plan did not address the labelling of the tubing of nutrition source. Record review of Resident #20's physician orders dated 03/08/2023 read, Pump: Isosource 1.5 kcal @ 50 ml/hr. per GT x 22 hrs. continuous every day. Turn off (down) at 4pm and Turn on (up) at 6pm. Observation on 5/21/23 at 9:20 am revealed Resident #20 lying in bed holding 3 stuffed animals. A family member was in the room holding her hand. The resident had Iso-Source Bag hanging on an IV pole. The time on the bag of the label was left blank. The label read, Iso-Source 5/21/23 room [ROOM NUMBER], 50 cc/hr. Observation and interview on 5/21/23 at 12:30 pm revealed Resident #20 lying in bed holding her 3 stuffed animals. Her family member was not in the room. This Surveyor asked RN A to review the label on resident's Iso-Source bag and she said the label should have the time it started on the bag. She said the purpose of the date was to ensure it was changed timely within 24 hours. She said the risk to the resident if they did not get changed timely was infection. She said the night shift nurse must have forgotten to record the time and she did not catch it during her morning rounds. She said she could not recall the last time she was in-serviced for how to label Iso-Source bags. In an interview on 5/21/23 at 1:34 pm with the DON, she said the night nurses had to change the Iso-Source bags and tubing every 24 hours. She said the nurses were supposed to document their initials, date, time, rate, resident's name, and room number for any resident who fed through a tube . She said it was important to ensure the bags were labelled properly so they could be changed every 24 hours. She said nurses often missed recording the time. She said the night nursing staff changed them between 7pm-10pm. She said as the DON, she made it a point to monitor the labels daily because based on her experience at other facilities, she knew it was problematic. She said if the bags were not changed timely, the risk to the resident was infection. She said she in-serviced staff shortly after her hired date six weeks ago . She said the failure occurred because she had not in-serviced staff recently. Record review of the manufacturer (Nestle) Hang Time Guidelines (no date) revealed the closed system enteral feeding should be replaced at least every 48 hours.

Based on observation, interview and record review, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 1 facility reviewed for posted staffing. -The facility failed to post the daily staffing information for 05/21/2023. This failure could affect all residents and place them at risk of not having access to information regarding staffing data and facility census. Findings include: Observation and record review on 05/21/23 at 9:27 a.m., with the DON and the Business Office Manager revealed there was no posting for 05/21/2023. When asked how do they monitor to ensure the required postings are updated and in place. The DON said, I have always seen it by the front door. But it's not there today. The BOM said, I have seen it on the wall by the nurses station. This Surveyor followed the DON and BOM to the nurses station. The posted staffing information was dated 05/15/2023. The DON said it was important to post daily staffing information to inform how many residents were in the facility, acuity for the resident and family to know. In an interview on 05/22/23 at 3:19 p.m., with the Administrator and the DON, the Administrator acknowledged the staffing should be posted daily. He said the Lead CNA was responsible for changing the posting daily. He said it was important to post the staffing information to know how many residents were in the facility. Staffing information for the potential people coming to the facility. He said the posting should be at the front and at nurses station. In an interview on 05/23/23 at 11:53a.m., with the Lead CNA, she said she worked Monday through Friday at this facility. She said she used facility provided app (application) to print the daily staffing information. She said she could not remember the last time she posted the staffing information but knew she needed to post it daily for family and residents to see the census. Record review of facility's Nurse Staffing Posting Information policy (undated) revealed read in part: .Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time .

Based on interview and record review, the facility failed to ensure one resident (Resident #1) of four residents reviewed for medications was provided with a drug regimen that was free from unnecessary drugs. -Resident #1 received a medication that had been discontinued prior to the re-admission. The deficient practice placed the resident at risk for complications resulting from receiving the unnecessary medication. Findings included: Record review of the Admission Record (printed 06/21/2022) for Resident #1 revealed she was [AGE] years of age, and originally admitted to the facility on [DATE]. She was readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged from the facility on 06/09/2022. Interview on 06/21/2022 at 10:51 a.m. with a family member of Resident #1 revealed she visited the resident the morning of 05/28/2022. She said she could not awaken the resident. She said she went to talk with the nurse, and the nurse informed her Resident #1 had received [MEDICATION(S)] (sleep-inducing medication) on the previous night. She said the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the resident did not tolerate it well. Record review of the May 2022 MAR for Resident #1 revealed she was administered one [MEDICATION(S)], 5 mg at 9:00 p.m. on 05/27/2022. Record review of the NN dated 05/27/2022 at 1:45 p.m. for Resident #1 revealed the resident was admitted with Hospice care. The NN reflected the Hospice nurse verified the medications. The NN was signed by LVN A. Record review of Resident #1's TO s (physician orders) dated 05/27/2022 reflected the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Hospice Medication Profile for benefit period 04/15/2022 to 06/13/2022 revealed no order for [MEDICATION(S)]. Interview on 06/21/2022 at 3:30 p.m. with LVN A she said she transcribed the orders from the TOs dated 05/27/2022 on to the MAR. She said she did not enter a [MEDICATION(S)] order onto the MAR. She said she thought the computer added it from Resident #1's previous admission. She acknowledged the [MEDICATION(S)] was administered to the resident. She said the [MEDICATION(S)] was discontinued from the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 06/21/2022 at 4:00 p.m . with the DON revealed the responsibility to check accuracy of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility policy admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the policy reflected all transfer orders needed to be approved by the provider upon admission.

Based on observation, interview and record review the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to ensure: - There were crumbs and food debris on the surfaces of the stove top and the burners, - The burners had food pieces stuck to them, - The griddle had food debris, grease splatters and burned on grime on the top surface ,- The oven racks had an accumulation of burnt food particles and grease on them, and - There were food particles inside the deep fat fryer. These failures could affect all residents who receive meals from the kitchen and place them at risk for foodborne illness. Findings Include: Observation of the kitchen on 4/19/2022 at 9:56 AM, with Dietary Manager (DM) revealed the following: - There were crumbs and food debris on the surfaces of the stove top and the burners, - The burners had food pieces stuck to them, - The griddle had food debris, grease splatters and burned on grime on the top surface ,- The oven racks had an accumulation of burnt food particles and grease on them, and - There were food particles inside the deep fat fryer. Interview with the DM on 4/19/2022 at 10:20 AM, regarding when equipment and deep fryer was cleaned. DM said she was not sure when it was cleaned, she called the lead cook, who said the deep fryer was used yesterday (4/18/22) and he was planning to clean deep fryer today because he was off-duty and just came back to work. DM said the equipment was supposed to be cleaned after each meal- breakfast, lunch, and dinner by the cook. Interview with the lead cook on 4/20/22 at 10:30 AM, he said the equipment should be cleaned after each meal and it prevents food poisoning and bacteria. Interview with Dietary Aide A on 4/21/22 at 8:30 AM, revealed she would wash and sanitize the serving utensils. She said non- food contact surfaces of equipment were not cleaned as often as was necessary to keep equipment free of accumulation of dirt, food particles and other debris. Interview with the DM on 4/21/22 at 9:00 AM, stated she was responsible for training staff on all requirements to ensure dietary requirements were met. The DM stated the dietary cleaning schedule would be done by dietary staff as assigned. In an interview on 4/20/22 at 10:00 AM, the administrator said he expected all kitchen staff to follow the cleaning and sanitizing schedule and follow the rules and regulations set forth by the state. Record review of facility's Nutrition Services Policies and Procedures Manual cleaning and Sanitizing Stationary Equipment and work surfaces, dated 6/2019, revealed stationary equipment and work surfaces will be cleaned appropriately after use. Record Review of the facility's policy titled Dining Services Orientation Guide Sanitation & Food Safety Sanitation & Safety, Food Storage and labeling, page 6 of 12 undated, documented: Bacteria find their way into food from poor sanitation of the kitchen and equipment, poor or unsafe food handling . Clean is when something is free from visible dirt. Sanitizing is when you disinfect the item or contact surfaces to be free of bacterial contamination and foods must be at least 6 inches from the floor.

Based on observation, interview, and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 6 residents (Residents #6 & #10) reviewed for PASRR Level I screenings. The facility did not ensure an accurate PASRR level 1 (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) screening was completed for Resident #6 and #10. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Resident #6 Record review of Resident #6's face sheet revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's care plans dated of 2/12/22 did not reveal a care plan for unspecified dementia with behavior and [CONDITION(S)] disorder. Record review of Resident #6's PASRR level 1 screening dated 2/11/22 revealed his PASRR screening was documented no for the question was their evidence or indicator the individual had mental illness. Record review of Resident #6's quarterly MDS dated [DATE] revealed she had a BIMS score of 10 out 15 indicating she was moderately impaired with cognition. Observation on 04/19/22 at 9:00 AM, revealed Resident #6 was ambulating with a walker in the hallway. The resident was awake alert and oriented. In an interview on 04/20/22 at 1:40 AM, the MDS coordinator LVN, stated she was responsible for the PASSR assessments. She stated she had guidance from the MDS RN for completion of Resident #6's PASSR level 1 assessment. She stated the MDS RN was off duty and also most of the PASRR level 1 comes from the hospital. MDS Coordinator LVN said she was going to call Resident #6's family to confirm the diagnosis. In an interview on 04/20/22 at 2:20 PM, the DON stated the MDS coordinator LVN was supposed to screen all residents for mental illness. DON stated that MDS nurses were responsible for PASSR screening for all residents and the facility follow the state guidelines for PASSR screening. In an interview on 04/21/22 at 2:40 PM, the DON stated , stated we will get this corrected. In an interview on 04/21/22 at 2:48 PM, the MDS coordinator LVN stated she would make the correction to indicate the presence of mental illness. Resident #10 Record review of Resident #59's face sheet revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. MDS section E ( behavior did not address mental illness. Record review of Resident #10's PASRR level 1 screening dated 2/8/22 read in part, .Is there evidence or an indicator this is an individual that has a Mental Illness? The answer was: No. Observation and interview on 4/19/22 at 9:10 AM, Resident #10 was sitting on the recliner with wife in the room, he was not able to respond to questions asked by the surveyor. The wife just said she was fine and was not able to engage in questions asked. Interview on 4/20/22 at 10:57 a.m., the MDS coordinator LVN said Resident #10 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was responsible for the accuracy of the PASRR screenings to ensure residents received services if needed. She said she was hired in October 2020 and reviewed the PASRR screenings in her newly created PASRR binders around March 2021. She said she thought she reviewed Resident #10's screening but must have missed it. She said upon hire she was provided with a PASRR guide but was not instructed to review screenings for residents who already resided in the facility. Interview on 4/21/22 at 11:45 AM, the Administrator said the MDS Coordinator RN oversaw the PASRR program by. reviewing the PASSR screenings for new admissions weekly to ensure accuracy. The Administrator said she was off duty. In an interview on 04/21/22 at 12: 46 PM, the DON stated the MDS Coordinator screen PASSR and she does not know it and she have to asked the MDS Coordinator and they did not have a policy for PASRR screening. DON said the facility follows the (state) guidelines for the PASSR screening. DON said MDS coordinator RN was off duty for family emergency. In an interview on 04/21/22 at 4:35 PM, the Administrator stated he did not know what diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated a PASRR level 1 was to be completed on all residents. He stated the facility follows the (state) guidelines for completion. Record review of Texas Health and Human Services Detailed Item by Item Guide for completing the PASRR Level I Screening Form for Referring Entities Version 1.0 dated November 2019 provided by the Administrator read in part, .Section C: PASRR Screen . Intent: this section is to be completed by the referring entity for people suspected of having mental illness, or an intellectual or developmental disability. Steps for Assessment: A. conduct psychiatric diagnostic evaluation or identify current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Mental Illness . a mental illness is defined as the following: a [CONDITION(S)], mood paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability. Record review of Texas Health and Human Services Mental Illness/Dementia Resident Review form dated September 2018 provided by the social worker read in part, .Definition of MI: a [CONDITION(S)], mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; but not a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] No policy for PASRR screening was provided before exit on 4/21/22 at 5:10 PM

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #22 and #1) reviewed for infection control. 1. The facility failed to ensure CNA B washed her hands or used alcohol-based hand sanitizer while performing incontinent care for Resident #22. 2. The facility failed to ensure CNA C washed her hands or used alcohol-based hand sanitizer while performing incontinent and indwelling catheter care for Resident #1. These deficient practices could place residents at risk for infection. Findings include: Resident #22 Record review of the face sheet revealed Resident #22 was admitted on [DATE], was an [AGE] year old-male whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #22's admission MDS assessment dated [DATE], revealed a BIMS of 5 out of 15, which indicated severe impaired cognition. He required extensive assistance from one-person physical assist for dressing, toilet use, and personal hygiene. He was always continent of bowel and bladder. Care plan revision dated 3/6/22 had Resident #22 potential /actual impairment to skin integrity related to decreased mobility, incontinence, dementia, fragile fragile skin, impaired circulation and the goal was to maintain or develop clean and intact skin. Observation on 04/19/22 at 10:20 AM, Resident #22 was lying in bed awake, cover sheet and blanket wet with yellowish fluid. The yellowish fluid was the nectar thicken liquid Surveyor put the call light in the restroom on, the housekeeper responded, then checked on resident then went and call CNA C. CNA C responded to Resident #22's room at 10:25 AM, surveyor showed her the wet cover sheet and blanket on the resident. CNA C picked up a pair of clean gloves and picked up the soiled linen from the bed and dropped it on the floor. Then took off the dirty gloves without washing hands and stated I am going to get the nurse. At 10:28 AM, CNA C and the DON entered room to perform incontinent care, CNA C donned cleaned gloves without hand washing, opened Resident #22's drawer and got clean brief and wipes and placed it on the bedside table. At 10:29 AM, CNA B came in the room washed hands and donned cleaned gloves and performed incontinent care, opened up a clean brief on the bedside table, then put the clean wipes inside the clean brief, then undo resident dirty brief and was picking the wipes from the brief to clean resident perineal area, penis, scrotum several times, then changed gloves without washing hands, don cleaned gloves, she then repositioned resident to his right side, cleaned resident buttocks, then picked up the same brief she had wet wipes and placed it on the resident without washing hands used the same gloves to repositioned resident, picked his pillows and cover resident in bed, then took trash to the door then washed hands. Interview with CNA B on 4/20/22 at 1:30 PM, regarding the incontinent care she performed. She said she was nervous and she forgot to change gloves, she said she was supposed to change gloves 3 times or depending how soiled the resident was . She said she had training before resuming work. CNA B said she should have washed her hands or used hand sanitizer between gloves changes during incontinent care because it was a risk for infection. Resident #1 Record review of Resident #1's face sheet revealed she was a [AGE] year female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's admission MDS assessment, dated 1/25/22, revealed a BIMS of 14 out of 15, which indicated no impaired cognition. She required extensive assistance from one-person physical assist for dressing, toilet use, and personal hygiene. He was always continent of bowel with [CONDITION(S)] ( bag attached to incised loop of bowel that collects fecal matter) and bladder indwelling catheter. Record review of the comprehensive care plan dated 1/31/22 addressed Resident #1's indwelling Catheter: Will be/remain secured free from catheter-related trauma through review date. Indwelling catheter: Change catheter per MD orders, Position catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor for sign/symptoms of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter Observation on 04/20/22 at 12:10 PM, Resident #1 was lying in bed awake, alert, oriented to name, time and place. Resident #1 had an indwelling catheter to the bedside drainage with 100 cc yellow urine in bag. CNA C and CNA D provided Resident #1 with incontinent and indwelling catheter care CNA C uncovered Resident #1 her indwelling catheter was not secured to her thigh, the tubing was tucked in her brief and caused an indentation mark on her thigh. CNA C washed hands and donned cleaned gloves, used the wet wipes and cleaned the perineal area, groins, then doffed dirty gloves without washing hands or using hand sanitizer on the bedside table, repositioned Resident #1 to her right side then donned a clean pair of gloves without washing hands or using hand sanitizer and then put a cleaned brief on Resident #1. During an interview on 4/20/22 at 00:00, CNA C said she was nervous, said she had in-services every two weeks on infection control. She said she knew she messed up during incontinent care and not washing hands or using sanitizer could result in bacteria and infection. During an interview on 04/21/22 at 1:00 PM, the DON said the nurses were supposed to checked indwelling catheter every shift to make sure it was secured During an interview with the DON on 4/21/2022 at 11:15 AM, the DON and the ADON/LVN said they both conduct in-services in the facility. The DON said she used in-service checklist for CNA B and CNA C which showed staff were supposed to remove gloves and wash hands or use sanitizer after using dirty gloves and before donning clean gloves. The DON stated that it was her expectation the competency checklist be followed. The DON stated not washing or sanitizing hands after removing soiled gloves risked cross contamination and was a concern and it could spread bacteria and infection. The DON said CNA B and CNA C just started, and they did not have any skilled check list for incontinent care. In an interview on 4/21/22 at 12:06 PM, the ADON/LVN revealed she would be monitoring and in servicing on incontinent care to CNAs now . The ADON/LVN stated it was her expectation that hands be washed or sanitized after removing soiled gloves. The ADON/LVN stated infections could occur. The ADON said CNAs B and C were agency nurses and she did the in-services before starting work on the unit. The ADON/LVN said she would look for checklists. No checklists was presented to surveyor before exit on 4/21/22. Record review of the facility's Handwashing/Hand Hygiene policy (Revised August 2019) read in part: .This facility considers hand hygiene the primary means or prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . h. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves . 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infection. Applying and Removing Gloves- 1. Perform hand hygiene before applying non-sterile gloves .

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of one treatment cart on the 400 hall. The facility failed to ensure an unattended treatment cart with biologicals was secured in a locked storage room at the end of the 400 hall. This deficient practice could place residents at risk for loss of wound care biologicals and place residents at risk of access to hazards. Findings include: During an observation 04/19/2022 at 11:50 A.M, the door to the beauty salon currently used for storage at the end of the 400 hall was open and accessible. The treatment cart was visible from the hall. The cart was unlocked and unattended by staff. No residents or visitors were in the area. An inventory of the treatment cart at the time of the observation accompanied by the DON revealed: Drawer #1: [MEDICATION(S)] Sodium topical ointment tubes (Non-steroidal anti-[CONDITION(S)] drug) Iodosorb (Iodine type antiseptic to promote wounds a clean healing wound environment) [MEDICATION(S)] (Wound and burn treatment beneficial to promote management through all phases of wound healing [MEDICATION(S)] (Treats fungal infections) Scissors Drawer #2: Xeroform (Dressing to cover and protect wounds to keep the air out to promote healing) Honey Alginate (cleans wounds) Drawer #3: [MEDICATION(S)] (Antiseptic used to prevent infection) Hy[DATE]%(Antimicrobial wound cleanser) Derminal wound cleanser (Antiseptic wound cleanser) Alginate Wound Dressing (Dressing to provide a dry environment for wounds with excessive drainage for wound healing) Drawer #4 Miscellaneous wound dressing supplies gauze, kerlix, tape Drawer #5 General supplies Wax paper, antiseptic cleaning wipes, alcohol hand gel In an interview on 04/19/2022 at 11:55 AM, the DON stated the treatment cart, and the storage door was to be locked and they usually are. She stated no residents come in this room and the nurses were responsible for keeping the cart and the room locked. The DON said the risk someone could get into them and take something that could cause harm or injury. In an interview on 04/19/22 at 12:02 PM, MA D stated we lock all carts to make sure the residents cannot get into them. MA D said the risk was the residents getting something they should not have and hurt them. In an interview on 04/19/22 at 12:10 PM, LVN E said the carts were to be locked to keep the residents from getting into them. LVN E said the risk was the residents could get a hold of something they should not have, and it could hurt them. She said all nurses were responsible for making sure the carts were secured. Record review of the facility's policy revised November 2017 titled Medication Storage read in part, . It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms, according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilations, moisture control, segregations and security . 1. All drugs and biological will be stored in locked compartments . 2. Only authorized personnel will have access to the keys to locked compartments .

Based on interview and record review the facility failed to ensure residents had the right to receive visitors of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident for 34 of 34 residents reviewed for resident rights. The facility failed to ensure all residents had the right to unrestricted visitation hours inside the facility. This failure could place residents at risk for isolation, decreased emotional well-being and a diminished quality of life. Findings include: In a telephone interview on 3/22/22 at 1:33 p.m., the complainant said the CDC revised visitation guidelines stating that visitors and residents should have unlimited visitations. The facility was allowing visits between 6:00 a.m.-6:00 p.m. The complainant said many of the visitors work and were not able to attend during early hours. The complainant said there was a sign posted to the front door that said all visitations must end by 6pm. Observation on 3/23/22 at 1:40 p.m., revealed a sign posted on the door to the facility that read: .Due to the increase in the positively rate of COVID-19 in [ounty], all visitations must end by 6PM. No Visitor allowed inside after 6PM . Observation on 3/23/22 at 12:12 p.m., revealed a sign posted across from the nurse's station that read: .Due to the increase in the positively rate of COVID-19 in [County], all visitations must end by 6PM. No Visitor allowed inside after 6PM . In an interview on 3/23/22 at 1:40 p.m., RN A said the facility's visitation hours were from 6 a.m. to 6 p.m. She said staff did not encourage family to stay after 6 p.m. She said when they get new admits they let the family know visitation cut off was 6 p. m. She said the facility did not have COVID-19 positive residents in the facility. In an interview on 3/23/22 at 1:53 p.m., the DON said their COVID-19 unit was not active. They had no COVID-19 positive residents in the facility. She said visitation was restricted till 6 p.m. She said if a resident came from the hospital after 6 p.m. the facility allowed family to come and stay for little bit and then requested the family to leave so the resident could adjust to the new environment. She said the visitation hours were limited to 6 p.m., because the facility had more staff during day to assist with screening visitors prior to entering the facility. She said after 6 p.m., the floor nurse had to screen the visitors and take care of their assigned residents. She said the facility had limited supplies such as mask and gown. She said with COVID-19 guidelines facility had to provide mask and gown to each family member visiting the resident. She said sometimes 4 visitors would come and visit one resident and the facility had to provide mask and gown to each visitor. So, to try to limit the use of supplies facility restricted visitation hours to 6 p.m. In an interview on 3/23/22 at 3:52 p.m., the Receptionist said visitation hours were from 6 a.m. to 6 p.m., she said the facility did not allow visitors to stay after 6 p.m. She said if the family insisted on staying after 6 p.m., they would need to get approval from the Administrator. In an interview on 3/24/22 at 10:06 a.m., the Administrator said recommended visitation hours were from 6 a.m. to 6 p.m. The Administrator said they posted the sign to let people know that visitation was limited but we are not really restricting any visitors. The Administrator further said that someone coming to the door and reading that sign could get the impression we are limiting or restricting visitation, but we are not. He said they were remodeling/ putting in new carpet in the facility. He said because of traffic flow with visitors in the facility it was hard to lay the new carpet. He said the contractors had been working at night. So, to keep traffic flow down after 6 p.m. the facility posted that sign. Record review of facility's Resident Right to Access and Visitation policy (not dated) read in part: .It is the policy of this facility to support and facilitate the resident's right to receive visitors of their choosing, at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of other residents. 8. The facility will ensure all visitors enjoy full and equal visitation privileges consisted with resident preferences. 9. Facilities shall provide 24-hour access to other non-relative visitors who are visiting with the consent of the resident .

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1of 7 residents reviewed for quality of care. (CR#1) The facility failed to allow CR#1 back into the facility after she left from her doctor's appointment on 11/16/21 at 2PM. The resident attempted to return to the facility at 5 PM, but was denied. The facility made CR#1 sit outside in a wheelchair from 8PM until she was sent to the hospital on 11/17/21 at 2AM, during which the facility refused her access to her personal belongings, food, medications, or incontinence care. An Immediate Jeopardy (IJ) was identified on 12/1/2021 at 4:30 PM. While the IJ was removed on 12/8/21 at 5:30 PM, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a delay of appropriate medical treatment and a worsening of a resident's condition. Findings included: Record review of CR #1's face sheet dated 12/7/2021 indicated CR#1 admitted to the facility on [DATE] and was discharged on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's quarterly MDS dated [DATE] indicated a BIMS of 15 indicating her to be cognitively intact. Further review of CR #1's MDS revealed she required total dependence with two staff to assist with all ADLS. Review of CR#1's MDS indicated she would remain in the facility and was not planning to discharge. Record review of CR #1's care plan dated 10/27/21 indicated CR#1 had an impaired vision and is a risk for falls, injury and decline in functional ability due to [CONDITION(S)] in both eyes. Interventions included assist with visual aids such as eyeglasses or large print books. Record review of CR#1's physician order dated 11/16/21 written by the DON read, Resident to be evaluated/tx prior to returning to facility per [Physician G]. Record review of CR#1's November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 did not receive [MEDICATION(S)] (for Alzheimer's), [MEDICATION(S)] (for pain), [MEDICATION(S)], [MEDICATION(S)], Omeprazole, [MEDICATION(S)] Solution (eye drops), [MEDICATION(S)] Solution (eye drops), [MEDICATION(S)] D3, Cosamin (for joint discomfort), and Calcium tablet. Record review of CR #1's eInteract Transfer Form dated 11/16/21 indicated CR #1 was transferred to the hospital, with reason for discharge stating, daughter did not explain. Record review of CR #1's nursing note dated 11/16/21 read, Patient is not in the facility right now. Call Administrator before readmitting the patient back. Record review of CR #1's emergency room notes dated 11/16/21 at 7:18 PM read in part, [CR#1] presents to the ED for evaluation of wellness adult health check for medical clearance to return to skilled nursing facility. [CR#1's family member] reported EMS suggested she take [CR#1] to emergency room and said that [CR#1's] eyes were abnormal and rolling back. [CR#1] denies any loss of consciousness or [CONDITION(S)] . Vitals stable. Patient is discharged back to skilled nursing facility. However, we received a call back from the skilled nursing facility declining the patient, stating that they are unable to meet the patient's needs . In an interview on 11/23/21 at 11:46 AM with The Administrator, he stated CR #1 had an appointment on 11/16/21 to go to the eye doctor. He stated he was informed by the EMT that while CR #1 was on the van getting strapped in, the EMS stated CR#1 zoned out and her eyes rolled back into her head for a second. The Administrator stated the medical director informed them to call the eye doctor and give them the information on what the EMT saw on CR#1, due to the eye roll having the possibility of being something neurological. The Administrator stated he was informed that CR #1 needed to go to the emergency room to be evaluated and treated to rule out stroke or brain bleed. He stated CR #1's family were made aware of what the doctor said and CR#1 and the family both refused to go to the ER. The Administrator stated they could not take CR #1 back to the facility before she was cleared from the hospital, as the doctor ordered, to rule out any stroke. In an interview on 11/23/21 at 12:55 PM with the BOM, she stated she informed CR#1's family member that they could not meet the needs of her at the time and could not accept her back at the facility. The BOM stated she was made aware that CR #1's eyes rolled over in her head while in the EMS van. The BOM stated CR#1 arrived at the facility around 11:30pm, after being made aware that the facility could no longer meet her needs. The BOM stated CR#1 arrived in a private ambulance and was sitting in the front lobby from around 11:30 PM until 2AM when the police contacted EMS to send CR #1 to the hospital. In an interview on 11/23/21 at 3:06 PM with CR #1, she starts crying immediately at the start of the interview and states the facility threw her out of her home of 8 years as if she was a criminal. CR#1 was able to recall the events leading up to her going to the eye doctor's appointment and stated she informed the EMS that her eyes did not roll in her head as he stated. CR#1 stated she refused to go to the ER and said she will continue going to her eye appointment. CR #1 stated when they were finished with the eye appointment the administrator called and informed her that she needed to go the ER to be checked out before returning to the facility. CR #1 stated she refused, and the administrator continued to say she needed to go get checked out before she could return to the facility. CR #1 stated after going back and forth, she finally decided to go to the ER, which was a stand-alone clinic to the main hospital. CR#1 stated she was checked out by the ER nurse and doctor who cleared her to return to the facility. CR#1 stated after completing the ER visit, they called the facility to be picked up and the receptionist told her they could not take her back until she received the medical release. CR #1's family member took the form to the facility which stated she was medically cleared to return back to the facility. CR #1 stated she begged the BOM to allow her into the facility for the night and she could discharge her properly tomorrow morning. CR#1 stated the BOM refused and CR#1 sat in the front of the building until the police called 911 to send her to the hospital around 2 AM. CR#1 stated she was without care since 1PM, so approximately 12 hours. In an interview on 11/23/21 at 3:15 PM with CR#1's family member, she stated she showed the BOM and the receptionist the form indicating CR#1 was able to return back to the facility. CR#1's family member informed the BOM that she was in the van with CR#1 on the way to her doctors' appointment and she didn't see anything abnormal with CR#1 as the EMT stated. CR#1's family member stated she begged the BOM to allow CR#1 into the facility as it was late at night and the BOM refused, stating they could no longer meet CR #1's need. She stated she asked what needs they could no longer meet, and she stated the BOM never gave her a clear answer. In an interview on 11/30/21 at 5:43 PM with CR #1 she stated she is trying to adjust to the new facility, but it is hard. She stated she has been in the same place for 8 years, so trying to get used to everyone is hard for her. She stated she cries often at night and has started taking her anxiety medications again. During the interview, CR#1 became very tearful and said she wishes this incident never happened. She stated she is without a lot of her personal belongings as the facility will not let her family members go to collect her belongings. CR#1 stated she has special equipment, such as a mattress, bed remote, TV remote and eating utensils that the family purchased to make things easier for her. She stated those items are still at the facility and they are not allowed to enter due to a trespassing order the administrator stated he put against them. In an interview on 12/1/21 at 5:15 PM with the BOM, she stated when CR#1 returned to the building around 8 PM, CR #1 stated she was hungry and the BOM offered her jello and water. The BOM stated incontinent care was not provided. The BOM stated CR#1 asked her several times to allow her in the building to sleep for the night and then be discharge properly. The BOM stated CR#1 could not come into the building as they were not able to meet her needs any longer. In an interview on 12/1/21 at 1:45 PM with Physician H, he stated the facility had tried to discharge CR#1 multiple times but found by the State that the discharges were inappropriate. He stated previously CR#1 was going to see her psychiatrist every six months, now, she will be going monthly to ensure she is handing this situation well. This was determined to be an Immediate Jeopardy (IJ) on 12/1/21 at 4:30 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on 12/1/21 at 5:03 PM In an interview on 12/2/21 at 12:03 PM with the SW, she stated She did not discharge CR#1. She stated during the fair hearing, her discharge was resolved and that she was not going to be discharged . She stated CR#1 won the discharge appeal and that proceedings should be stopped for any discharge. The SW stated on 11/16/21 she was not present during the incident with CR#1 In an interview on 12/6/21 at 11:49 AM with RN A, she stated she works PRN at the facility. She stated on 11/16/21 she worked with CR#1 during 6AM-6PM shift. She stated CR#1 had an eye appointment and she gathered the paperwork together. RN A stated during her shift, nothing was abnormal with CR#1. She stated she was alert and able to make her needs known. She stated when she was leaving for the end of her shift, she gave report to LVN A and informed her that CR#1 was at an appointment and was not back yet. She stated when she left for the evening, CR#1 was still not back at the facility. The Administrator and DON were notified on 12/1/21 at 4:30 PM an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the IJ template on 12/1/21 at 5:03 PM and a plan of removal was requested. The following Plan of Removal was submitted and accepted on 12/7/21 at 4:35 PM: Plan to remove immediate jeopardy [CR#1] is no longer in the facility. At this time, [NAME] Gardens has sent an e-mail to the [family member], one of the [family members] is the RP, to start the admission process. Delivery to these recipients or groups is complete, but no delivery notification was sent by the destination server: 3 emails have been sent all delivered no response. Resident #1 has a hearing date of 22 [DATE]. the medical director needed information to form a medical opinion if we can meet this residents needs. The IDT team needs accurate information on the condition of the resident to make a decision. RP was asked for this information on 16 and 17 [DATE], it was never received. If the family responds that they would like us to start this process, we will start the evaluation. Residents family took immediate need items on 16 [DATE]. Additional items were collected, on 24 [DATE]. On 24 [DATE] family stated they would have a moving company pick up the remaining items and would let us know the date. On 16 [DATE] the family requested a lock on her door, the facility complied and placed a lock on the door. All items have been available to pick when they would like to pick them up. The lock was placed at family request. In our policy: Admission/Readmission/Return to Facility Involving a COC Orders The patient/resident status must be known prior to the patient/resident arriving to the facility. Hospital visit has since been received and will be evaluated. ED encounter notes were received 17 [DATE]. At this time, [NAME] Gardens has sent 2 e-mails to the daughters, one of the daughters is the RP, to start the admission process. Evaluation will start when the family request that we start the process. RP will be notified by the DON/designee Patient/resident needs must be able to be met. Since the information on the residents condition was never received how would we be able to determine her needs. Resident's personal, consulting physician was contacted to date no response has been received. Medical Director tried to contact her Doctor and to date has not received a return call. If the RP request us to start the evaluation process the RP will be notified by the Social Worker or the DON. Patient/residents with unknown status can't be at the facility. The facility and the medical director would need medical information to assess the needs of the resident. Readmission to Facility If a resident is transferred to the hospital due to a resident's clinical or behavioral condition, the facility will evaluate the resident to determine: Accurate status of resident's condition to ensure the resident's needs are within the facility's scope of care based on its facility assessment. Hospital paperwork has now been received and will be evaluated. Facility is awaiting response from the RP on their desire to start the admission process. Any pending denial of a residents return to the facility must be reported to the Administrator, DON and the medical director. The Administrator will then report findings the Governing Body. Ad-Hoc QAPI meeting was held on 12/1/2021, with the Medical Director, NHA (Nursing Home Administrator), DON, and Unit Manager, Social Worker and BOM to review the alleged deficiencies, policies and procedures, and the plan for removal of immediacy. On 12/1/2021, the Social Worker completed an audit of the discharges for the last 30 days ensuring proper discharge. No issues were found. On 12/1/2021 the Social Worker reviewed the discharges coming up for the next 72 hours to ensure no issues identified. None were found. Also, on 12/1/21, In-service was given to LNFA, DON, Social Worker and the ADON on Safe and effective discharge planning. HR/BOM provided the training. HR/BOM was trained by the Governing Body President on proper discharge/transfer and resident rights. Discharge Planning Process, Readmission to Facility, Residents Rights. HR/BOM in person and Governing Body President on phone (President is a NP well versed in the NF/SNF area). This in-service reviewed our policies and procedures on proper discharge of a resident, discharge planning, readmission to the facility and resident rights. Focus was also given to the safety of the resident throughout the process. Also, on 12/1/21, In-service was given on quality of care for residents returning to the facility. In-service provided to LNFA, DON, Social Worker and the ADON. HR/BOM provided the training. HR/BOM was trained by the Governing Body on quality of care. HR/BOM in person, Governing Body President on phone. Our policy was reviewed in depth on quality of care and the importance of it in everything we do. We also reviewed our goal of providing care and services to attain or maintain his/her highest practical physical, mental and psychosocial well-being. This training included expectations and responsibility of facility to the resident in the event of a pending discharge and or entry delay. The need for care continuation including meds, food and needed adls were emphasized. QI tool Quality of Care for a discharged resident coming back to the facility Social Worker/designee will complete this tool. This will be done at discharge. Administrator/DON/designee will monitor the tool. Questions developed by Administrator/DON/SW. This form was developed to monitor residents that are coming back to the facility. It has questions on it like was the resident offered a meal or a snack, Was the physician notified of the return, Were any new orders received, Were any concerns identified Will start being used 12/2/21. QI tool Discharge Notice Audit Tool will start being used 12/2/21. These QI tools will ensure compliance. Any identified concern from the QI tools will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. This tool was developed to monitor admission, transfer and discharge rights. It has questions on it like is there documentation regarding the basis of the discharge, was the physicians orders related to the transfer complied with, was a discharge summary provided to the receiving facility. 1. Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). a. Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. b. Notify resident and/or resident representative. c. Contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements. d. Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: i. Resident status, including baseline and current mental, behavioral and functional status and recent vital signs; ii. Current diagnosis, allergies and reasons for transfer/discharge; iii. Contact information of the practitioner responsible for the care of the resident; iv. Resident representative information including contact information; v. Current medications (including when last received), treatments, most recent relevant lab and/or radiological findings and recent immunizations; vi. Special instructions or precautions for ongoing care to include precautions such as isolation or contact; vii. Special risks such as risk for falls, elopement, bleeding or pressure injury and/or aspiration precautions; viii. Comprehensive care plan goals, and ix. Any other documentation, as applicable, to ensure a safe and effective transition of care. e. A copy of any Advance Directive, Durable Power of Attorney, DNR or Withholding or Withdrawing of Life-Sustaining Treatment forms should be sent with the resident. f. The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record. g. Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand. h. Document assessment findings and other relevant information regarding the transfer in the medical record. i. Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. j. Provide transfer notice as soon as practicable to resident and representative. k. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. l. In case of discharge, notice requirements and procedures for facility-initiated discharges shall be followed. The residents Doctor is contacted if we can't reach them we contact the Medical Director. The resident is taken care of until they are transferred. Any and all of the residents belongings are available to be taken at any time. The Administrator and DON have been trained by the Governing Body President on Safe and effective discharge planning. Administrator and DON are the abuse coordinators. They are involved in the development of the POR and the training. Facility staff are currently being trained on residents' rights, discharge transfer requirements and quality of care. Training will be completed by the Administrator/DON/Social Worker/designee. Training in process currently. Employees will be trained prior to caring for patients. All residents were assessed for quality of care deficiencies, none of them were affected. Completed 12/2/21. QI tool Quality of Care Questionnaire was used to access quality of care. No issues were found. This was completed 12/2/21. QI Tool was completed by DON/ADON/Designee. This tool was developed to ensure quality of care It has questions on it like do you have any concerns with your stay, any concerns with the staff, any concerns with the activities, do you have any concerns with your therapy or your progression and does your room meet your needs. Surveyor Monitored the plan of removal as follows: In an interview on 12/7/21 with the administrator, DON, SW, BOM, RN B, all were able to inform surveyor of proper discharge planning process. Record review of the discharges in the last 30 days indicated they were all planned and/or received a NONMC from insurance provider. Record review of the discharge audit tool dated 12/3/21, 12/5/21 and 12/6/21 indicated no issues with the discharges. Record review of the facility policy titled Requesting, Refusing and/or Discontinuing care or Treatment dated February 2021 read in part, Residents and resident representatives have the right to request, refuse or discontinue treatment. Treatment refers to medical care .and interventions provided . Record review revealed in-services were completed for all nurses on both shifts and weekend staff regarding requesting, refusing discharge, care and treatment. Record review of the facility policy titled Resident Rights dated December 2016 read in part, Employees shall treat all residents with kindness, respect and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: self-determination .be supported by the facility in exercising his or her rights . Record review of in-services dated 12/2/21 indicated an in-service was completed on resident rights for all staff for both shifts. Record review of in-services dated 12/2/21 indicated an in-service was completed on Discharge planning process. The Administrator and DON was informed the Immediate Jeopardy was removed on 12/8/21 at 5:30 PM. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review; it was determined the facility failed to ensure all residents were free from psychological abuse and neglect for 1 of 7 residents reviewed for neglect (CR#1). The facility failed to adhere to residents' rights/self-determination, when CR#1 refused to go to the emergency room to be checked out for an eye roll to rule out stroke or [CONDITION(S)]. The facility failed to ensure CR #1 was free from psychological abuse and retaliation. These failures placed facility residents at risk of abuse and neglect. Findings included: Record review of CR #1's face sheet dated 12/7/2021 indicated CR#1 admitted to the facility on [DATE] and was discharged on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's quarterly MDS dated [DATE] indicated a BIMS of 15 indicating her to be cognitively intact. Further review of CR #1's MDS revealed she required total dependence with two staff to assist with all ADLS. Review of CR#1's MDS indicated she would remain in the facility and was not planning to discharge. Record review of CR #1's care plan dated 10/27/21 indicated CR#1 had an impaired vision and was a risk for falls, injury and decline in functional ability due to [CONDITION(S)] in both eyes. Interventions included assist with visual aids such as eyeglasses or large print books. Further review of CR#1's care plan did not indicate any discharge plans. Record review of CR #1's care plan dated 10/27/21 indicated CR#1 used antidepressant medications. The goal was for CR#1 to have decreased episode of depression. Interventions includes monitors medication side effects of medication. Record review of CR #1's care plan dated 10/27/21 indicated CR#1 had an ADL self-care performance deficit and was at risk for not having needs met in timely matter. Interventions include CR#1 requires two staff and [mechanical] lift to transfer resident, two person assist for bed mobility and repositioning and personal hygiene. Record review of CR #1's care plan dated 10/27/21 indicated CR#1 has limited mobility and unable to move her bilateral lower extremities and her left upper extremity. Interventions included assist resident with activities, encourage to participate in ADLS to improve strength and mobility status and mobility was total dependence with one person via wheelchair. Record review of CR#1's physician's order dated 11/16/21 written by the DON read, Resident to be evaluated/treat prior to returning to facility per [Physician G]. Record review of CR#1's November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 did not receive [MEDICATION(S)] 10mg (for Alzheimer's), [MEDICATION(S)] 600mg (for [CONDITION(S)] and pain), [MEDICATION(S)] 15 ML, [MEDICATION(S)] 25 MCG, Omeprazole 20mg, [MEDICATION(S)] Solution 1 drop (eye drops), [MEDICATION(S)] Solution 1 drop in both eyes, [MEDICATION(S)] D3 250mg, Cosamin 1 capsule (for joint discomfort), and Calcium tablet. Observation of facility postings indicated the Administrator was the abuse preventionist. In an interview on 11/23/21 at 10:36 AM RN B she stated she thinks the lock was on CR#1's door due to her having personal property in the room and her not being in the facility. In an interview on 11/23/21 at 11:46 AM the Administrator stated he was informed on 11/16/21 by Physician G that CR #1 needed to go to the emergency room to be evaluated and treated to rule out stroke or brain bleed. He stated CR #1's family were made aware of what Physician G said and CR#1 and the family both refused to go to the ER. The Administrator stated they could not take CR #1 back to the facility before she was cleared from the hospital, as the doctor ordered, to rule out any stroke. In an interview on 11/23/21 at 3:06 PM with CR #1, at the new facility, she starts crying immediately at the start of the interview and states the facility threw her out of her home of 8 years as if she was a criminal. CR#1 was able to recall the events leading up to her going to the eye doctor's appointment, but stated she wants to forget it all because she feels sick to her stomach about the incidents. CR #1 stated when they were finished with the eye appointment the administrator called and informed her that she needed to go the ER to be checked out before returning to the facility. CR #1 stated she refused, and the administrator continued to say she needed to go get checked out before she could return to the facility. CR #1 stated after going back and forth, she finally decided to go to the ER, which was a stand-alone clinic to the main hospital. CR#1 stated she was checked out by the ER nurse and doctor who cleared her to return to the facility. CR#1 stated after completing the ER visit, they called the facility to be picked up and the receptionist told her they could not take her back until she received the medical release. CR #1's family member took the form to the facility which stated she was medically cleared to return back to the facility. During the interview with CR#1, she was tearful and stated she felt as if the facility ganged up on her and plotted to get her out of the facility. CR#1 stated in the last six months, the facility has attempted to discharge her several times, but they lost the appeal. CR#1 stated the facility told her she is costing them too much to care for her and that the staff are leaving because of her. In an interview on 11/23/21 at 3:15 PM with CR#1's family member, she stated she begged the BOM to allow CR#1 to come into the facility for the night and they could discuss the issue tomorrow during the day. She stated she informed the BOM that CR#1 had not eaten, had any medication, or been changed since she first left to go to the eye doctor's appointment early afternoon. CR#1's family member stated the BOM refused to allow CR#1 into the building. CR#1's family member stated CR#1 had been outside for so long, there was several times she fell asleep slumped over in her chair. The family member also stated the facility endangered CR#1's mental health with kicking her out of her home with only the clothes on her back. She stated she was only able to grab a few gowns out of CR#1's room before the EMS arrived to take her back to the hospital. Observation on 11/23/21 at 10:34 AM, CR#1's room door was locked with a key lock. In an interview on 11/30/21 at 5:43 PM with CR#1 she stated she was trying to adjust to the new facility, but it was hard. She stated she had been in the same place for 8 years, so trying to get used to everyone was hard for her. She stated she cried often at night and had started taking her anxiety medications again. During the interview, CR#1 became very tearful and said she wished the incident never happened. She stated she was without a lot of her personal belongings as the facility will not let her family members go to collect her belongings. CR#1 stated she had special equipment, such as a mattress, bed remote, TV remote and eating utensils her family purchased to make things easier for her. She stated those items are still at the facility and they are not allowed to enter due to a trespassing order the administrator stated he put against them. CR#1 stated she felt the facility retaliated against her for the level of care she required and for speaking out against staff who are mean to her. CR#1 stated several times the staff came into her room and if they have a disagreement, the staff will tell her this is why no one wants to work with your or you are the reason all the staff are quitting. She stated when staff told her this, it made her feel sad. She stated she did not want anyone to quit because of her and she cries about it. CR#1 stated when her or her family member asks for a grievance form, they are told by staff that there are none in the building. In an interview on 12/1/21 at 1:45 PM with Physician H, he stated the facility has tried to discharge CR#1 multiple times but was found by the State that the discharges were inappropriate. He stated previously CR#1 was going to see her psychiatrist every six months, now, she will be going monthly to ensure she was handing this situation well. In an interview on 12/6/21 at 11:49 AM with RN A, she stated she works PRN at the facility. She stated on 11/16/21 she worked with CR#1 during 6AM-6PM shift. She stated CR#1 had an eye appointment and she gathered the paperwork together. RN A stated during her shift, nothing was abnormal with CR#1. She stated she was alert and able to make her needs known. She stated when she was leaving for the end of her shift, she gave report to LVN A and informed her that CR#1 was at an appointment and was not back yet. She stated when she left for the evening, CR#1 was still not back at the facility. Record review of the facility policy titled Resident Rights dated December 2016 read in part, Employees shall treat all residents with kindness, respect and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: self-determination .be supported by the facility in exercising his or her rights . Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2011 read in part, Residents have the right to be free from abuse, neglect misappropriation of resident property . This includes but is not limited to . mental abuse . 5) Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, combative, cognitive or emotional problems .

Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility for 1 of 7 (CR#1) residents reviewed for transfer and discharged rights being that: The facility failed to permit CR# 1 to remain in the facility, and not transfer or discharge the resident from the facility. CR #1 was not allowed to return to the facility following an eye doctor's appointment on 11/16/21 due to the facility no longer being able to meet CR #1's needs. After refusing CR#1 to enter back into the facility, CR#1 only had three personal gowns in her possession. CR#1 was without all of her personal effects such as special mattress the family purchased, special bed and TV remote and hand utensils that allow her to eat food properly This failure could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: Record review of CR #1's face sheet dated 12/7/2021 indicated CR#1 admitted to the facility on [DATE] and was discharged on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's quarterly MDS dated [DATE] indicated a BIMS of 15 indicating her to be cognitively intact. Further review of CR #1's MDS revealed she required total dependence with two staff to assist with all ADLS. Review of CR#1's MDS indicated she would remain in the facility and was not planning to discharge. Record review of CR #1's care plan dated 10/27/21 indicated CR#1 had an impaired vision and was a risk for falls, injury and decline in functional ability due to [CONDITION(S)] in both eyes. Interventions included assist with visual aids such as eyeglasses or large print books. Further review of CR#1's care plan did not indicate any discharge plans. Record review of CR #1's eInteract Transfer Form dated 11/16/21 indicated CR #1 was transferred to the hospital, with reason for discharge stating, daughter did not explain. Record review of CR #1's nursing note written by LVN A dated 11/16/21 read, Patient is not in the facility right now. Call Administrator before readmitting the patient back. Record review of CR #1's physician order dated 11/16/201 read, Resident to be evaluated/tx prior to returning to facility per Physician G. Record review of CR#1's financial record indicated CR #1 was given an involuntarily discharge notice on 03/11/2021 and on 08/10/2021 the Texas Health and Human Services Commission - Appeals Division, found that the involuntary discharge of CR #1 was reversed on 10/27/21 Record review of CR#1's hospital admission record's dated 11/17/21 at 1:48 AM read in part, [CR#1] presents to the ED for evaluation of well adult check that began on yesterday . Prior to appointment, [CR#1's] were reportedly not normal . [CR#1] was taken to [the emergency room ] where she was given the clear to go back . When [CR#1] arrived to the home, the staff there said they couldn't meet [CR#1's] needs and told them she was unable to stay there . Of note the police were actually called to the scene .family did want to be back however, [the facility] would not take her back into the facility. On arrival they requested ambulance service to bring patient here to [the hospital]. Further review of the hospital admission records read in part, The initial complaint of getting medical clearance due to some abnormal eye findings does not need further work up. [CR#1] saw an ophthalmologist after noted abnormalities and was cleared. To me she is at her baseline with no significant abnormalities that are new. Unfortunately, she was not accepted back to her facility due to the time of night and will need admission for placement. In an interview on 11/30/21 at 11:08 AM with EMT C, he stated upon arriving to the facility, he helped load CR#1 on the van and completed a mental check on her. He asked her date and time and she was able to answer correctly. He stated he noticed she rolled her eyes back for a brief second and asked was she okay. EMT C stated he told CR#1's family member she should take CR#1to ER to get her checked out, as he was concerned about the eye roll. He stated he was still on the premise of the facility and went to tell the administrator his finding and they refused to go to the ER. EMT C stated rolled her eyes meant her eyes went up in her head and saw the white of her eyeballs. He stated he was looking directly at the patient and being casual and that's when he noticed the eye roll, but it wasn't long, just a quick eye roll. EMT C stated he did not believe it was a casual eye roll. He stated when the EMS services transfer patients, if things are out of the ordinary, they will notify the facility if they make a recommendation and if the family or resident refuses. EMT C stated CR#1 was in her right might mind and made the decision not to go to the ER. In an interview on 11/23/21 at 11:46 AM with The Administrator, he stated CR #1 had an appointment on 11/16/21 to go to the eye doctor. He stated he was informed by the EMT that while CR #1 was on the van getting strapped in, the EMS stated CR#1 zoned out and her eyes rolled back into her head for a second. He stated the EMT stated he asked CR #1 if she was okay, which she responded she was and the EMT stated he told the CR#1's family member what he saw and informed her to have it checked out in the ER and CR#1 and the family member refused and stated they wanted to go to the eye doctor appointment. The Administrator stated the EMT called the facility and informed them of what they saw with CR#1. The Administrator stated he called the medical director, after trying to reach the CR #1's primary doctor, but unable to reach him. The Administrator stated the medical director informed them to call the eye doctor and give them the information on what the EMT saw on CR#1, due to the eye roll having the possibility of being something neurological. The Administrator stated he was informed by Physician G that CR #1 needed to go to the emergency room to be evaluated and treated to rule out stroke or brain bleed. He stated CR #1's family was made aware of what the doctor said and CR#1 and the family both refused to go to the ER. The Administrator stated they could not take CR #1 back to the facility before she was cleared from the hospital, as the doctor ordered, to rule out any stroke. The Administrator stated they could not have a resident in the facility without knowing their true condition. He also stated they were going with what their readmission policy stated. The administrator stated the facility wanted CR#1 to be checked out to ensure she was not having any neurological issues. In an interview on 11/23/21 at 3:06 PM with CR #1, she started crying immediately at the start of the interview and stated the facility threw her out of her home of 8 years as if she was a criminal. CR #1 stated on 11/16/21 she had an eye doctor appointment and when transportation arrived, it was stretcher van, which she normally goes to appointments by a wheelchair van. She stated she told them she could not go to an eye appointment in a stretcher and after an hour, a wheelchair van came. She stated when she was put in the van, EMT C came to strap her wheelchair down. CR #1 stated during this, EMT C began to ask her the month, date, date and who the current president was. CR #1 stated she answered the questions and then asked EMT C was he a doctor and why he was asking her so many questions, as no one has ever asked her those questions when they put her in the van. She then stated EMT C went to tell her family member she needed to take CR #1 to the ER as something was wrong with her eyes. CR #1 asked what was wrong with her eyes and said she was going to an eye doctor's appointment and they can check out anything wrong with her eyes. CR#1 denied that her eyes rolled back during the conversation with EMT C. CR #1 and her family member refused to go to the ER and informed EMT C to take her to her doctors' appointment. CR #1 stated when she arrived at her eye appointment the eye doctor came out to ask her if she was ok as the administrator called and told him about what occurred on the EMS van. CR #1 stated she informed the eye doctor that her eyes did not roll into the back of her head and she did not lose consciousness, as EMT C informed the administrator. CR #1 stated she completed her eye appointment and was there for a couple hours as she had not seen the eye doctor in a long time. CR #1 stated when they were finished with the eye appointment the administrator called and informed her, she needed to go the ER to be checked out before returning to the facility. CR #1 stated she refused, and the administrator continued to say she needed to go get checked out before she could return to the facility. CR #1 stated after going back and forth, she finally decided to go to the ER, which was a stand-alone clinic to the main hospital. CR#1 stated she was checked out by the ER nurse and doctor who cleared her to return to the facility. CR#1 stated after completing the ER visit, they called the facility for her to be picked up and the receptionist told her they could not take her back until she received the medical release. CR #1's family member took the form to the facility which stated she was medically cleared to return back to the facility. CR#1 was admitted to an alternate facility on 11/18/21 after being discharged from the hospital. In an interview on 11/30/21 at 11:53 AM with the administrator, he stated on 11/16/21 he called the eye doctors office to check on CR#1. The administrator stated CR#1's family called back to say they were going to an urgent care to get the patient checked out. He called the urgent care and gave them a background of what happened to CR#1. The administrator stated he later got a phone call from the nurse at the urgent care and the nurse stated CR#1 was clear to return back to the facility. He stated he asked the urgent care nurse what was done to CR#1 and was told nothing was done, as nothing was needed, and that CR#1 could return to the facility. The Administrator stated he informed the nurse that Physician G order was specific, which for CR#1 to go to the emergency room to rule out stroke or neurological stroke. He stated the urgent care that CR#1 went to did not have the capability to rule out the needed things. He stated he did not understand why CR#1 and family would not comply to ensure she was medically fine. The administrator stated if a resident was in the facility and refused treatment, they would contact the resident's doctor, document the refusal and education completed with family and resident. Record review of CR #1's emergency room notes dated 11/16/21 at 7:18 PM read in part, [CR#1] presents to the ED for evaluation of wellness adult health check for medical clearance to return to skilled nursing facility. [CR#1's family member] reported EMS suggested she take [CR#1] to emergency room and said that [CR#1's] eyes were abnormal and rolling back. [CR#1] denies any loss of consciousness or [CONDITION(S)] . Vitals stable. Patient is discharged back to skilled nursing facility. However, we received a call back from the skilled nursing facility declining the patient, stating that they are unable to meet the patient's needs . In an interview on 11/30/21 at 9:25 AM with the Director of Emergency Services, she stated CR#1 was seen in the emergency roiagnom on [DATE] at 7:18 PM. She stated the reason for admission was a wellness checkup. She stated the doctor checked on CR#1 and found she was medically cleared and could return back to the facility. In an interview on 11/23/21 at 3:15 PM with CR#1's family member, stated she took the medical release form to the facility and spoke with the receptionist and the BOM. She stated the BOM informed her they could not take CR#1 back because they could no longer meet her needs as she needed to be checked to rule out stroke or [CONDITION(S)]. CR #1's family member stated they showed the BOM and the receptionist the form indicating CR#1 was able to return back to the facility. CR#1's family member informed the BOM that she was in the van with CR#1 on the way to her doctors' appointment and she did not see anything abnormal with CR#1 as the EMT stated. CR#1's family member stated she begged the BOM to allow CR#1 into the facility as it was late at night and the BOM refused, stating they could no longer meet CR #1's need. She stated she asked what needs they could no longer meet, and she stated the BOM never gave her a clear answer. In an interview on 11/30/21 at 1:21 PM with the receptionist, she stated when she arrived for her shift, she was informed CR#1 would not be returning to the facility. She stated CR#1 was at an eye appointment and she was informed she was not going to be accepted back to the facility. The receptionist stated she was informed by either the BOM or the administrator that if there were any issues to call either of them. She stated CR#1's family members came to the facility and told her that CR#1 would be back at the facility shortly. She told the family member the facility was not able to take CR#1 back, but was not sure of what was occurring, only relaying the message. The receptionist stated a couple hours later, CR#1's family member came back and showed her the medical clearance paperwork. She stated she called the administrator and informed him of the paperwork and was told they could not accept her back. The receptionist stated CR#1's family member asked for EMS to pick up CR#1 from the hospital ER and the BOM told her she could not pick CR#1 up. The receptionist stated CR#1's family called for a cab to pick up CR#1 to return her to the facility. She stated while one of CR#1's family members was at the facility; they also called the police to assist in getting CR#1 back into the facility. She stated the police came around 8pm. The receptionist stated when she was leaving, it was close to 2AM and CR #1 was still sitting in the front of the building. In an interview on 11/23/21 at 12:55 PM the BOM stated that evening (11/16/21), the receptionist called her around 6pm and stated CR#1's family member was in the facility and she was letting them know the resident was on the way back from the ER. She stated CR#1's family member stated she did not understand why the facility could no longer meet the needs of CR #1. The BOM stated she informed CR#1's family member that they could not meet the needs of her at the time and could not accept her back at the facility. The BOM stated she was informed by the administrator that CR #1's eyes rolled over in her head and when CR #1 was asked questions, CR #1 was not responding. The BOM stated she was made aware that CR #1's family was aware of what happened to CR#1 while in the EMS van and CR #1's family stated CR #1 was fine. The BOM stated she was made aware the EMT called the facility and informed the administrator on what happened to CR#1 and that it was his opinion that she should go to the ER. The BOM stated CR #1 refused to go to the ER and went to her eye doctor appointment. The BOM stated she was made aware CR #1's eye doctor stated CR#1 was fine. The BOM stated the facility did not know what was going on with CR #1 and why she rolled her eyes. The BOM stated all of this information was reiterated to CR#1's family member, who stated nothing happened to CR #1 and that the family stated the resident wanted to be at the facility. The BOM stated CR#1 arrived at the facility around 11:30pm, after being made aware that the facility could no longer meet her needs. The BOM stated CR#1 arrived in a private ambulance and was sitting in the front lobby from around 11:30 PM until 2AM when the police contacted EMS to send CR#1 to the hospital. In an interview on 11/30/21 at 1:08 PM the BOM stated around 11:30 PM CR#1's family member and CR#1 arrived at the facility in a white van. CR#1's family called the police to assist in the situation. The BOM stated a police officer came into the building and asked her are about CR#1 and she told them they could not meet her needs or accept her back. In an interview with CR#1 on 11/23/21 at 3:00 PM, she stated she begged the BOM to allow her into the facility for the night and she could discharge her properly tomorrow morning. CR#1 stated the BOM refused and CR#1 sat in the front of the building until the police called 911 to send her to the hospital around 2 AM. In an interview on 11/30/21 at 7:42 AM with Officer B, he stated he was on the call regarding CR#1 and the facility told CR#1 and family members they could no longer care for her based on a policy they had. Officer B stated the facility was asked what the reason was they could not allow CR#1 to return to the facility and they continued to say they just could not take care of her anymore. Officer B stated CR#1 came back to the facility and the officers could not force them to take her back, so the police called an ambulance to come pick her up CR#1 and take her back to the hospital as it was almost 2AM. In an interview on 11/23/21 at 1:09 PM with the Social Worker (SW), she stated she was not at work when CR #1 was not allowed to return to the facility. The SW stated she was told that while CR#1 was leaving the facility to go to her eye doctorsappointment, the EMS saw CR#1's eyes roll into the back of her head. The SW stated the facility stated they needed to rule out any seizures or anything wrong with CR #1 before she could return back to the facility. The SW stated the family refused the resident to be sent to the ER but sent her to urgent care. She stated the facility could not accept her back due to them having to rule out if she had a stroke or that anything was wrong with CR#1. The SW stated she was responsible for overseeing the discharge process within the facility, but she will also coordinate with physical therapy. In an interview on 11/29/21 at 3:42 PM with the Hospital SW, she stated she received a call on 11/16/21 from the doctor at their standalone emergency room , who asked her to get involved in the case regarding CR#1. She stated she was made aware the EMS stated CR #1's eyes rolled in the back of her head and the EMS notified the administrator. The Hospital SW stated CR #1 went to the ER to get cleared, which she was cleared by the MD, and the facility stated they could no longer meet CR#1's needs and refused to allow her to return to the facility. The Hospital SW stated she spoke with the facility receptionist, who stated they could no longer meet the needs of CR#1. The hospital SW stated she called the Administrator, and he informed her they can no longer meet CR#1's needs and would not be taking her back. She stated she asked the administrator what the needs were not being able to be met, but she did not get a response regarding that. She stated CR# 1's family wanted her to return to the facility and CR#1 also wanted to return. The hospital SW stated when she returned to work the next day, she saw CR#1 was sent back to the ER, but not sure where she discharged to as she was not her patient. In an interview on 11/30/21 at 10:28 AM with the DON, she stated on 11/16/21 she was in the building and she stated the EMS picked CR #1 up for her appointment and they observed her eyes rolling back and they got scared, because it took a minute for her to respond. She stated the EMS called the administrator and told him what was going on. She stated Physician G called her and told her CR#1 needed to be transferred to the hospital to be evaluated to be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she was not aware if CR#1 went to the hospital or was evaluated anywhere, but the administrator informed her they could no longer meet the needs of the patient, as no paperwork was given. The DON stated when she was called regarding the EMT's findings in the van, she stated she was in a patient's room. She stated she did not check on CR#1, as she was made aware she was still alert and could make her needs known. In an interview on 11/30/21 at 4:19 PM with Physician G , he stated he received a call from the administrator, describing what occurred on the van with CR#1. He stated the family wanted to take her to the eye doctor appointment and not seek medical treatment. He stated the eye roll could have been a possible [CONDITION(S)]/[CONDITION(S)] episode. Physician G stated he told the administrator to have EMS take CR#1 to the hospital to ensure nothing was wrong with her. He stated to his knowledge, there was nothing done for CR#1 to rule out [CONDITION(S)] or [CONDITION(S)], but he was not contacted after he gave the order for sending CR#1 to the emergency room . Physician G was also not the primary doctor for CR#1 and that he was familiar with the extensive care CR#1 required. He also stated he did not work with CR#1 often. In an interview on 11/30/21 at 5:43 PM CR #1 she stated she was trying to adjust to the new facility, but it was hard. She stated she has been in the same place for 8 years, so trying to get used to everyone was hard for her. She stated she cried often at night and had started taking her anxiety medications again. During the interview, CR#1 became very tearful and said she wished this incident never happened. She stated she was without a lot of her personal belongings as the facility will not let her family members go to collect her belongings. CR#1 stated she had special equipment, such as a mattress, bed remote, TV remote and eating utensils that the family purchased to make things easier for her. She stated those items are still at the facility and they are not allowed to enter due to a trespassing order the administrator stated he put against them. In an interview on 12/1/21 at 1:45 PM with Physician H he stated he was not made aware that anything happened with CR#1 until the family called him that evening stating the facility said she had a change in condition and could not take her back into the facility. Physician H stated this had been going on for months with the facility trying to discharge CR#1 without justification due to the amount of care she requires. He stated the facility stated they cannot meet her needs for the way she wanted to be cared for. He stated he never got a call from the facility stating anything occurred with CR#1, which had been his patient for several years. Physician H stated the facility has his personal cell phone and his nurse practitioners phone number. He stated he also never received a message from his answering service indicating a call was made for him regarding CR#1. He stated previously CR#1 was going to see her psychiatrist every six months, now, she will be going monthly to ensure she was handing this situation well. Physician H stated he would have sent her to theER on ly after asking questions about her vitals, level on consciousness and alertness. He stated he would not have sent CR#1 to the ER based off an eye roll. In an interview on 12/2/21 at 12:03 PM the SW, she stated She did not discharge CR#1. She stated during the fair hearing (10/17/2021), her discharge was resolved and that she was not going to be discharged . She stated CR#1 won the discharge appeal and the proceedings of a discharge should have been stopped. The SW stated on 11/16/21 she was not present during the incident with CR#1. She stated she did see CR#1 before she got on the van and she said hello to her, and she was fine; she looked fine and spoke to her. She was not consulted about not being able to meet CR#1's needs as it was all clinical. The SW stated the family and resident want to fight all the time. In an interview on 12/6/21 at 11:49 AM with RN A, she stated she works PRN at the facility. She stated on 11/16/21 she worked with CR#1 during 6AM-6PM shift. She stated CR#1 had an eye appointment and she gathered the paperwork together. RN A stated during her shift, nothing was abnormal with CR#1. She stated she was alert and able to make her needs known. She stated when she was leaving for the end of her shift, she gave report to LVN A and informed her that CR#1 was at an appointment and was not back yet. She stated when she left for the evening, CR#1 was still not back at the facility. Record review of the facility policy titled Requesting, Refusing and/or Discontinuing care or Treatment dated February 2021 read in part, Residents and resident representatives have the right to request, refuse or discontinue treatment. Treatment refers to medical care .and interventions provided . Record review revealed in-services were completed for all nurses on both shifts and weekend staff regarding requesting, refusing discharge, care and treatment. Record review of the facility policy titled Resident Rights dated December 2016 read in part, Employees shall treat all residents with kindness, respect and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: self-determination .be supported by the facility in exercising his or her rights .

Based on observation, interview, and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents reviewed for quality of care. (Resident #1) in that - LVN A did not thoroughly assessed Resident #1 after an unwitnessed fall and did not send the resident to the hospital in a timely manner. Resident #1 was admitted to the hospital with [REDACTED]. This failure affected one resident and placed her at risk of bleeding, injuries and a decline in health. Resident #1: Record review of the face sheet for Resident #1 revealed that she as an [AGE] year-old female admitted to the facility on [DATE], discharged on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the file revealed that the comprehensive MDS assessment was not due yet. Record review of the admission physician orders dated 1/30/19 revealed an order for [REDACTED]. Record review of the care plans dated 1/30/19 revealed a care plan for use of anticoagulant therapy due to Afib. Interventions included daily skin infections, report abnormalities to the nurse, take precautions to avoid falls . Record review of additional care plan dated 1/31/19 revealed actual fall with injury, change in condition .send to the hospital and admitted with subdural hematoma. Record review of incident report dated 1/31/19 at 5:45 am revealed it was completed by LVN A. The report read in part that the night nurse was notified by CNA A that the resident was on the floor beside her bed. Both LVN A and the night nurse assessed the resident and with the assistance of two other staff and a Hoyer lift, moved her to the bed. No pain reported, and the resident had slight bleeding from her already bruised right lower leg and left forearm. The report indicated that the MD was informed and the family. Record review of Resident #1's neuro checks signed by LVN A after the fall revealed that they were started on 1/31/19 at 6:00 am and stopped at 11:45 am. There were no neuro checks documented after that. Record review of progress note written by the ADON on 1/31/19 at 2:53 pm revealed that she spoke with the resident's family member that said Resident #1 told her she hit her head when she fell in the morning .NP notified who gave orders to send the resident to the hospital. Record review of progress note written by the ADON on 1/31/19 at 3:43 pm revealed that Resident #1 was picked up by EMS and transferred to the hospital at that time. Record review of Resident #1's hospital records dated 1/31/19 revealed the resident was admitted to the hospital's ICU unit due to a fall with a subdural and subarachnoid hemorrhages, likely posttraumatic. In an interview on 02/01/19 at 2:20 pm The DON said that she reported the incident to the State because Resident #1 reported that LVN A was mean to her telling her if she tried to get out of bed again, he was going to consider it suicide and call the police. She said she also reported the incident because LVN A did not assess the resident properly after the fall and did not follow the NP instructions to send her out. The DON said that the resident was on anticoagulants and the LVN should have taken that in to consideration when assessing the resident. She said the resident was not sent out to the hospital until around 3:30 pm the day of the fall. She said staff should be very specific when calling the MD and explain to them if a resident that was taking anti-coagulants had a fall that was unwitnessed. In an interview on 02/01/19 at 2:45 pm the ADON said she was made aware of Resident #1's fall on 1/31/19 at 8:30 am by the DON. She said she went and assessed the resident at around 10:30 am that day and did not see any bruises in the resident's face but she had bruises on her arms and shoulder. She said the resident was alert and oriented and did not complained of anything to her. She said later that day, she received a call from the resident's family member that told her the resident may have possibly hit the head and had a bruise on her face. The ADON said that she went back to the room to assess the resident and noticed an area in the orbital left area that looked like dots were forming like Petechiae She said she called the NP and gave her the new information and asked for the resident to the transferred to the hospital for evaluation. The ADON said the NP said to her that she thought the resident was sent out in the morning. The ADON said she did not do neuro checks on the resident. Interview on 02/01/19 at 3:38 pm the hospital nurse said that since the CT scans showed no signs that the bleeding was growing, and the resident was alert and oriented after the fall, she did not needed surgery and was going to be moved to a regular room. She said the resident was admitted with multiple bruises in her arms, shoulder, face and the top of her head. Observation and interview on 02/01/19 at 3:55 pm Resident #1 was observed in an ICU bed in the hospital. The resident was awake and alert and oriented. She said that at around 5:30 am the day before, she felt hot, so she decided to try to get out of bed. She said that she got tangled in the sheets and fell out of bed. When asked, she said she did not remember if she hit her head or not. She said her only complaint was that she kept telling the staff she wanted to go to the hospital because she was short of breath, but she was not sent out right away. Observation revealed she had multiple, large bruises in her arms, shoulder, and the top of the head. She also had a fading bruise on her left side of the face, by the left eye and a bruise on the left side of her chin. In a phone interview on 2/4/19 at 1:50 pm, LVN A said he had just arrived for his shift on 1/31/19 before 6:00 am and was called to a room to assist with a fall. He said he did not know the resident as she had been admitted to the facility the night before. He said the resident was on the floor on the left side of the bed. LVN A said he assisted staff to put her back in her bed an did a full assessment with the night nurse. He said the night nurse called the MD and left a message about the fall. He said he did not see any bruises to the resident's face, but she had bruises on her arms and leg and was bleeding from her left chin. LVN A said the resident was stable on his shift and said he assessed her multiple times. He said that in the morning, he received a call from a doctor's office medical assistant saying that Resident #1 had called asking to be sent to the hospital because she was short of breath. He said he assessed the resident at that moment and she had no changes from the time of the fall, and her O2 stats were normal. He said this was at around 10:30 am. He said he gave report to the MA that said she would tell the doctor. LVN A said that the NP called right after that and he gave her report on the resident's condition. He said that the NP told him to ask the ADON to assess the resident and report to her. He said that he then received a text from the NP saying, if the resident insist, or there were changes to send her to the ER. He denied receiving specific instructions to send her out to the hospital. LVN A said after that, at around noon, a therapist informed him of a bruise on the resident's shoulder. He said he could not determine if the bruise was new or not. When asked why the neurochecks stopped at 11:45 am, he said he was asked by the DON not to go in the resident's room again because the family member reported that he had made threatening statements to Resident #1 about calling the police if she fell again. LVN A insisted that he did not see bruises in the resident's face. In a phone interview on 02/04/19 at 2:18 pm, the NP stated that she felt LVN A was not giving her the entire picture of Resident #1's condition after the fall so she was giving instructions based on what he was telling her. She said she told LVN A in the morning to sent the resident out if she had any changes or she wanted to go to the hospital. The NP said that was the reason why she was surprised in the afternoon when the ADON called her and informed her the resident may have a head injury and needed to be send out. In a phone interview on 02/04/19 at 2:30 pm with Resident #1's family member, she said she visited the resident the day of the fall at around noon and the resident told her about the fall. She said the resident had visible bruises in her arms and some cuts covered with bandages. She said the resident landed on her readers, so the arm was bruised. She said the resident had a visible bruise in her face. She said later that day she received a call from the ADON and she asked the ADON why the facility had not sent the resident to the hospital. She said the ADON told her because there were no signs she hit her head and her vitals were normal. She said it was then that she told the ADON the resident did hit her head and had facial bruising. She said the resident was then send to the hospital. Record review of the facility policy titled falls- clinical protocol (dated 2012) revealed in part: .the nurse shall assess and document/report the following: vital signs, recent injury, neurological status .the staff with the physician guidance, will follow up on any fall with associated injury until the resident is stable .delayed complications such as late fractured and major bruising may occur hours or several days after a fall, while signs of subdural hematoma or other intracranial bleeding could occur up to several weeks after a fall .

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility with pressure ulcers received appropriate care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 2 of 5 residents reviewed for Pressure sores. (Resident #11 and #9) -The facility failed to accurately assess Resident #11's Stage 4 pressure sores on his bilateral buttocks, peri-rectal area, and sacral area upon admission. The facility identified the resident had multiple pressure ulcers, but failed to describe, and measure the wounds. -The facility failed to obtain treatment orders on admission, and provide treatment for [REDACTED]. -The facility failed to have an interim Care Plan for Resident #11 that addressed turning and repositioning, resident teaching, nutrition, and any other preventative measures to prevent worsening of the existing pressure ulcers. -The Charge Nurse was unaware that Resident #11 had pressure ulcers. -The facility failed to conduct wound care treatments as ordered by the physician for Resident #9. These failures resulted in an Immediate Jeopardy (IJ) on 11/02/17. While the IJ was lowered on 11/06/17, the facility remained out of compliance at the severity level of potential for more that minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected two residents, and placed 3 additional residents with skin breakdown, at risk for development, worsening of existing pressure ulcers, infections, pain, unnecessary hospitalization , extensive treatments, and possible death. Findings Included: Resident #11: Record review of Resident #11's clinical record revealed a [AGE] year old male admitted on [DATE]. [DIAGNOSES REDACTED]. Record review revealed the resident did not have an MDS assessment yet. Record review of the Admission assessment dated [DATE] and completed by LVN Y revealed in part: .admitting [DIAGNOSES REDACTED]. LNV Y recorded that the resident had pressure sores on the right and left buttock but did not specify the Stage or measurements. Further review of the admission assessment revealed that the resident was alert and oriented, had A Foley catheter, and was incontinent of bowel. Record review of Resident #11 physician orders dated 10/27/17 revealed no wound care treatment orders. Record review of the Braden scale attached to the Admission assessment and dated 10/27/17 revealed that it was completed but it did not indicate a score. Record review of nurses' notes dated 10/27/17 at 7:19 pm revealed in part: .received resident at around 3 pm .all meds faxed to the pharmacy and clarified with MD .resident is alert and oriented times 4 .multiple bed sores on coccyx area, Foley catheter, incontinent of bowel . Record review of nurses' note dated 10/27/17 at 11:52 pm revealed in part: .Foley catheter .resident on every two hour turning and repositioning .refused to reposition . There were no additional nurses' notes until 11/01/17. Record review of physician progress notes [REDACTED].#11 was alert and oriented x3. The summary revealed that the resident was paraplegic and had a chronic Foley catheter. There were no orders documented on this progress note. Record Review of the clinical chart on 11/01/17 revealed the resident had no care plans. Record review of the Physician's admission orders [REDACTED]. Record review of the October 2017 TAR for Resident #11 revealed no pressure ulcer treatments were provided. Record review of a list of residents requiring wound care treatments provided by the facility on 10/31/17 revealed Resident #11's name was not included on the list. Observation and interview on 11/01/17 at 10:30 a.m. revealed Resident #11 to be lying in bed. There was a pneumatic mattress on the bed. Resident #11 said he had Stage 4 pressure ulcers on his buttocks, and the facility was not treating them since he was admitted last week. Observation and interview on 11/01/17 at 10:31 a.m. revealed RN F and NP A to be at the nurses' station. RN F said she was the Charge Nurse for Resident #11. At that time, RN F was asked if Resident #11 had any skin breakdown. RN F said Resident #11 complained of pain the previous day, but she did not look at his skin. She said she was unaware of any skin breakdown. RN F was asked to assess Resident #11's skin. Observation and interview on 11/01/17 at 10:32 a.m. revealed NP A to be in Resident #11's room. The resident was turned onto his left side. Observation revealed several large open wounds. Observation of the wound on the right buttock revealed the bone was visible. NP A confirmed that there were no dressings on the wounds, and no dressings were observed in the disposable brief or bed linens when he repositioned the resident to the side. Further observation at the time revealed no soiled dressings in the trash cans. In further interview during the above observation, NP A said Physician A had seen the resident on Monday (10/30/17), and that the physician said the wounds needed to be debrided. At that time, RN F said there were no treatment orders since the resident was admitted . In an interview on 11/01/17 at 11:17 a.m., CNA T said she had provided hygiene care for Resident #11 and had never seen dressings on the wounds. She said she did not report not seeing dressings on the wounds because she assumed the nurses were aware the resident had wounds. Observation on 11/01/17 at 11:18 a.m. revealed NP A, RN F, CNA T and LVN L to be in Resident #11's room. Resident #11 was alert and oriented, and he granted verbal consent for the surveyor to photograph the wounds. Three photographs were taken. Observation at that time revealed NP A measured the wounds. He measured and verbalized the measurements as (length by width by depth): Right Buttock 8.0 x 7.0 x 4.5 centimeters (cm) and the bone was exposed. Coccygeal 5.0 x 8.0 x 7.0 cm Left Buttock 7.0 x 8.0 x 7.0 cm Base of Scrotum 7.0 x 3.0 x superficial depth. Observation at the time revealed that NP A provide wound care and applied dressings to each wound. NP A said he saw Resident #11 a month earlier at the resident's home, and the resident had tissue breakdown then. NP A said he would talk with the other Nurse Practitioner (NP B) about the wounds, and obtain treatment orders. In an interview on 11/01/17 at 2:20 p.m. with the MDS Coordinator, she said she had not completed any care plan for Resident #11 yet. In an interview on 11/01/17 at 2:21 p.m., RN L said He's (Resident #11) been here five days. We do a Care Plan in twenty one days. She verified there was no initial/interim care plan. In an interview on 11/01/17 at 2:30 p.m., LVN Y, who had completed and signed the Admission Assessment for Resident #11 said The day he (Resident #11) came in the wound care nurse (LVN Q) took over his wounds. She put dressings on them. I let her know when she looked at him to give me orders. She said she never received wound care orders. She said she did not initiate a Care Plan. LVN Y said she did not obtain a physician orders for the wounds upon admission for the resident. In an interview on 11/01/17 at 2:40 p.m., Wound care nurse LVN Q said I saw the resident a week ago. I work at another facility also. I saw him (Resident# 11) Monday and today. She said the resident had an order for [REDACTED]. She said that if a resident was admitted to the facility on days other than MWF, the nurses were supposed to put a wet to dry dressing until she was able to see them. Record review of a Physician's Nursing Home Visit dated 10/28/17 (presented by the facility on 11/02/17) revealed Physician A documented the resident had Stage 4 pressure ulcers that Needs aggressive wound care, ordered and discussed with nursing . The note did not indicate a wound care order, or that wound treatment was conducted during the visit. Record review of nurses note dated 11/01/17 at 7:29 pm completed by a physician assistant revealed in part: .patient examined today .right ischium stage 4: measure as 8cm x 6.5cm x 3cm with undermining from 11-4 o'clock with the deepest at 11 o'clock at 5.8 cm .moderate drainage, no foul odor .left ischium stage 4 measured 5.5 cmx 9.5 cmx x 6 cm with tunneling at 8 o'clock at 7 cm. no sloughing, moderate drainage .plan or care: patient in low air loss mattress, turn every 2 hrs. to offload wounds, local wound care and prn, hx of non-compliance. Refuse wound vac. Refuse [MEDICAL CONDITION] . Record review of a Nurse's Note dated 11/03/17 at 4:49 p.m. revealed that Resident #11 was assessed by Physician C. left ischium stage 4 remains stable .some active bleeding over the right ischium .peri-rectal wound: wound bed red, yellow with 30 % necrotic tissue .[MEDICAL CONDITION] for wound healing purpose. Patient declined at this time . Interview on 11/04/17 at 11:32 a.m. with the Administrator revealed Resident #11 had been sent to the hospital. He said Resident #11 was not discharged , but was sent to the hospital to receive a [MEDICAL CONDITION] to aide in wound healing. Record review of the telephone orders for Resident #11 revealed no order for a [MEDICAL CONDITION], no order to transfer to a hospital, and no order for discharge. Resident # 9 Record review of the Admission Record for Resident #9 revealed an [AGE] year old male was originally admitted to the facility on [DATE], then re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the most recent MDS assessment, dated 10/02/17, revealed the resident scored a '13' on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. The MDS revealed the resident required extensive assist from two persons for bed mobility, transfers, and extensive assist from one person for personal hygiene. He was always incontinent of bladder, and he had a [MEDICAL CONDITION] appliance. The MDS was documented as the resident was at risk for developing, but did not have any pressure ulcers at that time. Record review of the Physician's Telephone Order dated 10/27/17 at 10:00 a.m. revealed Sacrum/bilateral buttocks: Clean with mild soap and water. Apply [MEDICATION NAME] every three days. Record review of the October 2017 TAR for Resident #9 revealed no treatment was documented as conducted from 10/27/17 to 10/31/2017. Record review of Resident #9's Care Plan revealed a Focus area dated 10/30/17 that reflected . has a pressure ulcer to his right hip which now has an appearance of a stage 2 area no measurement given by MD (Medical Doctor) at this time . Interventions included in part: Administer treatments as ordered and monitor for effectiveness. Observation and interview on 10/31/17 at 5:20 p.m. revealed Resident #9 was in bed. He said he had just returned from [MEDICAL TREATMENT]. He said the wound care physician had changed the dressing, but staff here hasn't changed it in weeks. Observation on 10/31/17 at 5:27 p.m. with CNA P revealed there was a dressing on Resident #9's sacral area. It was dated 10/30/17. Record review of the November 2017 TAR for Resident #9 revealed no treatment was documented as conducted from 11/01/17 to 11/05/17. Observation on 11/01/17 at 9:20 a.m. with LVN D revealed Resident #9 to be lying in bed. When the resident turned, a dressing was visible. The date reflected 10/31/17. The surrounding area appeared to be excoriated. Record review of a nurse note dated 11/03/17 at 5:08 p.m. by NP B revealed the sacrum/bilateral buttocks presented with skin breakdown. Observation and interview on 11/05/17 at 12:05 p.m. with LVN M revealed Resident #9 to be lying flat in bed. The resident turned onto his left side. LVN M loosened the resident's disposable brief. There was no dressing on the resident and no dressing in the brief or linens. Excoriation with one small open area on each buttock, near the sacral area was noted. LVN M confirmed the open areas, then said no one had notified her that there was no dressing on the wounds. She said there was no treatment order, and that she would call the physician for an order. Review of the paper chart at that time revealed no discontinuation (D/C) order for the sacral wound treatment for [REDACTED]. In an interview on 11/05/17 at 12:18 p.m., LVN M said All we've been using is Zinc Oxide to the sacral area and [MEDICATION NAME] to the groin. LVN M presented the orders for the Zinc Oxide and [MEDICATION NAME]. LVN M then confirmed that the orders dated 10/27/17 at 10:00 a.m. that reflected Sacrum/bilateral buttocks: Clean with mild soap and water. Apply [MEDICATION NAME] every three days. had no D/C order. LVN M stated there should have been a dressing on the sacral/buttocks area. Observation on 11/05/17 at 12:19 pm revealed LVN M was unable to locate the sacral wound treatment on the November 2017 TAR. However, the surveyor was able to locate the treatment on the TAR. The TAR reflected the treatment was not signed as provided on 11/01/17 or 11/04/17. Review of the facility policy Preventing Pressure Ulcers revealed 1. Risk Assessment: risk assessment tools, such as the Braden scale, help caretakers recognize a patient's risk of developing pressure ulcers . 2. Skin Inspections: a patient's skin should be examined regularly for signs of pressure damage . The facility Administrator was notified on 11/01/17 at 3:53 p.m. that an IJ was identified and a POR was requested. The POR was submitted by the Administrator on 11/02/17. After several revisions, the final plan of removal was accepted on 11/02/17 at 2:05 p.m. The POR included in part: .On 11/1/2017 the Medical Doctor conducted a pressure injury risk assessment and a skin assessment on Resident #1. , the wound was measured, staged, an order was provided for treatment, The following were the physician orders . Peri-rectal wound: clean with normal saline, pat dry, apply [MEDICATION NAME] gel Daily and PRN after bowel movements .Right ischium and left ischium wounds: clean with normal saline, pat dry, apply Calcium alginate MWF and PRN when soiled as needed .Right ischium and left ischium wounds: clean with normal saline, pat dry, apply Calcium alginate MWF and PRN when soiled . Treatment was initiated as ordered. Appropriate revisions were made to the plan of care to reflect all current pressure injury prevention interventions. The treatment nurse reviewed the revised care plans with all staff scheduled and involved in the care of the resident on 11/1/2017 . Pressure injury risk assessments and skin assessments was completed for all residents on 11/1/2017 by the nursing management team. For those residents at risk, care plans would be reviewed and/or modified to ensure appropriate interventions. The treatment nurse reviewed the revised care plans with all staff involved in the care of at risk residents on 11/1/2017. -The facility policy regarding Pressure Injury Prevention was reviewed 11/1/2017 and updated to include pressure injury risk assessment and skin assessment to be completed upon admission. - Immediate education on wound care policy and procedures were initiated and all nursing staff would be in-serviced by the medical director and/or treatment nurse on the revised facility policy for Pressure Injury Prevention, prevention interventions, wound care, and timely reporting of skin concerns as well as initiating wound care orders or PRN orders when the wound care nurse is not available, also the in-service will include proper admission assessment process for patient so patient would not miss any orders upon admission. The in-service started 11/1/2017 and will be continue until all nursing staff are educated. No nurse staff will be reporting to duty without receiving the in-service for the above concerns. An in-service for all CNA includes but not limited to understand basic wound care, application of barrier cream , communication with nurses on any abnormal skin conditions such as redness, bruising , rashes etc., Understanding the different pressure points and the effectiveness of patient turning. Initiated 11/1/17 and will continue until all staff are in serviced no staff will report to work without receiving the in-service. -A wound care nurse will be schedule on daily (biases), to assist and treat all patients with wounds and all new admission. -An interim meeting with QA committee including our medical director and the wound care physician was conducted on the first of November 2017 to update polices and wound care practices . On 11/02/17 at 9:28 a.m. the Administrator requested a meeting with the survey team. The Administrator, Physician B, Physician C, NP B, the MDS Coordinator, and ADON A attended, along with three surveyors. The facility presented copies of texts regarding Resident #11, but they were all dated prior to the resident's re-admission to the facility on [DATE]. In an interview during the above meeting, Physician B said they were familiar with Resident #11. Physician B said they had tried various treatments, including [DEVICE] for the resident. She said the resident was non-compliant. In an interview during the above meeting Physician C said Resident #11 was non-compliant, and that he removed dressings himself. He said the resident would not turn himself either. In an interview during the above meeting NP B said the resident would remove the wound dressings. When the surveyor asked for documentation or care plan to address those issues including non-compliance, the two Physicians and the NP offered no explanation. During further interview on 11/2/17 at 9:30 am the Administrator said that the wound care nurse (LVN Q) conducted wound care for the resident but did not know how to document it in the computer. When asked why she didn't write a note instead of using the computer, no answer was provided. In an interview during the above meeting, Physician B said the nurse on duty was responsible to make sure the wounds were dressed. In an interview with the Administrator on 11/2/17 at 2:42 pm he said that he believe some of the reasons why this IJ happened is because the previous wound care nurse was in a car accident after the hurricane and he did not return. He said the previous DON was carrying everything on her shoulders. He said he informed her of the problems and the DON decided to eliminate the wound care nurse position and let the floor nurses do the wound care for the residents. In the meantime, he wanted to offer the wound care positon to another nurse, but wanted to hire somebody to cover her position before promoting her. While all the changes were happening, he believes some wound care treatments were not covered. The facility was monitored for the implementation of the plan from 11/2/17 to 11/6/17 with the following results: Record review of the Skin Assessments provided by the facility on 11/02/17 at 2:40 p.m. revealed assessments only for 31 of the 46 residents. One of the residents had two Skin Assessments from two different nurses, both dated 11/01/17. The two assessments were completely different from the other. Further monitor revealed all assessments completed as of 11/6/17 in the morning. Record review of the In-service logs provided revealed 13 staff members had been in-serviced on 1) Preventing pressure Ulcers/Turn Clock and 2) Preventative Skin Care, as of 11/3/17. Eight Staff members had been in-serviced on Wound Documentation, as of 11/3/17. Record review of continued in-servicing on 11/6/17 at 10:00 am revealed 17 additional staff members were in-serviced on wound assessment and documentation and 15 additional staff member were in-serviced on preventing pressure ulcers/turn clock. Interviews with nurses and CNAs during the monitoring revealed understanding of the wound care policy. The residents with Skin breakdown were observed during the monitoring and no concerns were observed. In an interview on 11/04/17 at 1:20 p.m. with the DON, she said she had only been the DON since 10/28/17. When asked what contributed to the IJ, she said the nurses were not aware of what needed to be done, and that there was no follow-through. On 11/06/17 at 10:47 am, the Administrator was informed the IJ was lowered. However, the facility remained out of compliance at a severity level of potential for more than actual harm with a scope identified as pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. According to the list provided by the facility there were 5 residents with skin breakdown.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for two of five residents reviewed neglect. (Resident # 11 and Resident #9) -The facility failed to accurately assess Resident #11's Stage 4 pressure sores on his bilateral buttocks, peri-rectal area, and sacral area upon admission. The facility identified the resident had multiple pressure ulcers, but failed to describe, and measure the wounds. -The facility failed to obtain treatment orders on admission, and provide treatment for [REDACTED]. -The facility failed to have an interim Care Plan for Resident #11 that addressed turning and repositioning, resident teaching, nutrition, and any other preventative measures to prevent worsening of the existing pressure ulcers. -The Charge Nurse was unaware that Resident #11 had pressure ulcers. -The facility failed to conduct wound care treatments as ordered by the physician for Resident #9. These failures resulted in an Immediate Jeopardy (IJ) on 11/02/17. While the IJ was lowered on 11/06/17, the facility remained out of compliance at the severity level of potential for more that minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected two residents, and placed 3 additional residents with skin breakdown, at risk for development, worsening of existing pressure ulcers, infections, pain, unnecessary hospitalization , extensive treatments, and possible death. Findings Included: Resident #11: Record review of Resident #11's clinical record revealed a [AGE] year old male admitted on [DATE]. [DIAGNOSES REDACTED]. Record review revealed the resident did not have an MDS assessment yet. Record review of the Admission assessment dated [DATE] and completed by LVN Y revealed in part: .admitting [DIAGNOSES REDACTED]. LNV Y recorded that the resident had pressure sores on the right and left buttock but did not specify the Stage or measurements. Further review of the admission assessment revealed that the resident was alert and oriented, had A Foley catheter, and was incontinent of bowel. Record review of Resident #11 physician orders dated 10/27/17 revealed no wound care treatment orders. Record review of the Braden scale attached to the Admission assessment and dated 10/27/17 revealed that it was completed but it did not indicate a score. Record review of nurses' notes dated 10/27/17 at 7:19 pm revealed in part: .received resident at around 3 pm .all meds faxed to the pharmacy and clarified with MD .resident is alert and oriented times 4 .multiple bed sores on coccyx area, Foley catheter, incontinent of bowel . Record review of nurses' note dated 10/27/17 at 11:52 pm revealed in part: .Foley catheter .resident on every two hour turning and repositioning .refused to reposition . There were no additional nurses' notes until 11/01/17. Record review of physician progress notes [REDACTED].#11 was alert and oriented x3. The summary revealed that the resident was paraplegic and had a chronic Foley catheter. There were no orders documented on this progress note. Record Review of the clinical chart on 11/01/17 revealed the resident had no care plans. Record review of the Physician's admission orders [REDACTED]. Record review of the October 2017 TAR for Resident #11 revealed no pressure ulcer treatments were provided. Record review of a list of residents requiring wound care treatments provided by the facility on 10/31/17 revealed Resident #11's name was not included on the list. Observation and interview on 11/01/17 at 10:30 a.m. revealed Resident #11 to be lying in bed. There was a pneumatic mattress on the bed. Resident #11 said he had Stage 4 pressure ulcers on his buttocks, and the facility was not treating them since he was admitted last week. Observation and interview on 11/01/17 at 10:31 a.m. revealed RN F and NP A to be at the nurses' station. RN F said she was the Charge Nurse for Resident #11. At that time, RN F was asked if Resident #11 had any skin breakdown. RN F said Resident #11 complained of pain the previous day, but she did not look at his skin. She said she was unaware of any skin breakdown. RN F was asked to assess Resident #11's skin. Observation and interview on 11/01/17 at 10:32 a.m. revealed NP A to be in Resident #11's room. The resident was turned onto his left side. Observation revealed several large open wounds. Observation of the wound on the right buttock revealed the bone was visible. NP A confirmed that there were no dressings on the wounds, and no dressings were observed in the disposable brief or bed linens when he repositioned the resident to the side. Further observation at the time revealed no soiled dressings in the trash cans. In further interview during the above observation, NP A said Physician A had seen the resident on Monday (10/30/17), and that the physician said the wounds needed to be debrided. At that time, RN F said there were no treatment orders since the resident was admitted . In an interview on 11/01/17 at 11:17 a.m., CNA T said she had provided hygiene care for Resident #11 and had never seen dressings on the wounds. She said she did not report not seeing dressings on the wounds because she assumed the nurses were aware the resident had wounds. Observation on 11/01/17 at 11:18 a.m. revealed NP A, RN F, CNA T and LVN L to be in Resident #11's room. Resident #11 was alert and oriented, and he granted verbal consent for the surveyor to photograph the wounds. Three photographs were taken. Observation at that time revealed NP A measured the wounds. He measured and verbalized the measurements as (length by width by depth): Right Buttock 8.0 x 7.0 x 4.5 centimeters (cm) and the bone was exposed. Coccygeal 5.0 x 8.0 x 7.0 cm Left Buttock 7.0 x 8.0 x 7.0 cm Base of Scrotum 7.0 x 3.0 x superficial depth. Observation at the time revealed that NP A provide wound care and applied dressings to each wound. NP A said he saw Resident #11 a month earlier at the resident's home, and the resident had tissue breakdown then. NP A said he would talk with the other Nurse Practitioner (NP B) about the wounds, and obtain treatment orders. In an interview on 11/01/17 at 2:20 p.m. with the MDS Coordinator, she said she had not completed any care plan for Resident #11 yet. In an interview on 11/01/17 at 2:21 p.m., RN L said He's (Resident #11) been here five days. We do a Care Plan in twenty one days. She verified there was no initial/interim care plan. In an interview on 11/01/17 at 2:30 p.m., LVN Y, who had completed and signed the Admission Assessment for Resident #11 said The day he (Resident #11) came in the wound care nurse (LVN Q) took over his wounds. She put dressings on them. I let her know when she looked at him to give me orders. She said she never received wound care orders. She said she did not initiate a Care Plan. LVN Y said she did not obtain a physician orders for the wounds upon admission for the resident. In an interview on 11/01/17 at 2:40 p.m., Wound care nurse LVN Q said I saw the resident a week ago. I work at another facility also. I saw him (Resident# 11) Monday and today. She said the resident had an order for [REDACTED]. She said that if a resident was admitted to the facility on days other than MWF, the nurses were supposed to put a wet to dry dressing until she was able to see them. Record review of a Physician's Nursing Home Visit dated 10/28/17 (presented by the facility on 11/02/17) revealed Physician A documented the resident had Stage 4 pressure ulcers that Needs aggressive wound care, ordered and discussed with nursing . The note did not indicate a wound care order, or that wound treatment was conducted during the visit. Record review of nurses note dated 11/01/17 at 7:29 pm completed by a physician assistant revealed in part: .patient examined today .right ischium stage 4: measure as 8cm x 6.5cm x 3cm with undermining from 11-4 o'clock with the deepest at 11 o'clock at 5.8 cm .moderate drainage, no foul odor .left ischium stage 4 measured 5.5 cmx 9.5 cmx x 6 cm with tunneling at 8 o'clock at 7 cm. no sloughing, moderate drainage .plan or care: patient in low air loss mattress, turn every 2 hrs. to offload wounds, local wound care and prn, hx of non-compliance. Refuse wound vac. Refuse [MEDICAL CONDITION] . Record review of a Nurse's Note dated 11/03/17 at 4:49 p.m. revealed that Resident #11 was assessed by Physician C. left ischium stage 4 remains stable .some active bleeding over the right ischium .peri-rectal wound: wound bed red, yellow with 30 % necrotic tissue .[MEDICAL CONDITION] for wound healing purpose. Patient declined at this time . Interview on 11/04/17 at 11:32 a.m. with the Administrator revealed Resident #11 had been sent to the hospital. He said Resident #11 was not discharged , but was sent to the hospital to receive a [MEDICAL CONDITION] to aide in wound healing. Record review of the telephone orders for Resident #11 revealed no order for a [MEDICAL CONDITION], no order to transfer to a hospital, and no order for discharge. Resident # 9 Record review of the Admission Record for Resident #9 revealed an [AGE] year old male was originally admitted to the facility on [DATE], then re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the most recent MDS assessment, dated 10/02/17, revealed the resident scored a '13' on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. The MDS revealed the resident required extensive assist from two persons for bed mobility, transfers, and extensive assist from one person for personal hygiene. He was always incontinent of bladder, and he had a [MEDICAL CONDITION] appliance. The MDS was documented as the resident was at risk for developing, but did not have any pressure ulcers at that time. Record review of the Physician's Telephone Order dated 10/27/17 at 10:00 a.m. revealed Sacrum/bilateral buttocks: Clean with mild soap and water. Apply [MEDICATION NAME] every three days. Record review of the October 2017 TAR for Resident #9 revealed no treatment was documented as conducted from 10/27/17 to 10/31/2017. Record review of Resident #9's Care Plan revealed a Focus area dated 10/30/17 that reflected . has a pressure ulcer to his right hip which now has an appearance of a stage 2 area no measurement given by MD (Medical Doctor) at this time . Interventions included in part: Administer treatments as ordered and monitor for effectiveness. Observation and interview on 10/31/17 at 5:20 p.m. revealed Resident #9 was in bed. He said he had just returned from [MEDICAL TREATMENT]. He said the wound care physician had changed the dressing, but staff here hasn't changed it in weeks. Observation on 10/31/17 at 5:27 p.m. with CNA P revealed there was a dressing on Resident #9's sacral area. It was dated 10/30/17. Record review of the November 2017 TAR for Resident #9 revealed no treatment was documented as conducted from 11/01/17 to 11/05/17. Observation on 11/01/17 at 9:20 a.m. with LVN D revealed Resident #9 to be lying in bed. When the resident turned, a dressing was visible. The date reflected 10/31/17. The surrounding area appeared to be excoriated. Record review of a nurse note dated 11/03/17 at 5:08 p.m. by NP B revealed the sacrum/bilateral buttocks presented with skin breakdown. Observation and interview on 11/05/17 at 12:05 p.m. with LVN M revealed Resident #9 to be lying flat in bed. The resident turned onto his left side. LVN M loosened the resident's disposable brief. There was no dressing on the resident and no dressing in the brief or linens. Excoriation with one small open area on each buttock, near the sacral area was noted. LVN M confirmed the open areas, then said no one had notified her that there was no dressing on the wounds. She said there was no treatment order, and that she would call the physician for an order. Review of the paper chart at that time revealed no discontinuation (D/C) order for the sacral wound treatment for [REDACTED]. In an interview on 11/05/17 at 12:18 p.m., LVN M said All we've been using is Zinc Oxide to the sacral area and [MEDICATION NAME] to the groin. LVN M presented the orders for the Zinc Oxide and [MEDICATION NAME]. LVN M then confirmed that the orders dated 10/27/17 at 10:00 a.m. that reflected Sacrum/bilateral buttocks: Clean with mild soap and water. Apply [MEDICATION NAME] every three days. had no D/C order. LVN M stated there should have been a dressing on the sacral/buttocks area. Observation on 11/05/17 at 12:19 pm revealed LVN M was unable to locate the sacral wound treatment on the November 2017 TAR. However, the surveyor was able to locate the treatment on the TAR. The TAR reflected the treatment was not signed as provided on 11/01/17 or 11/04/17. Record review of the facility policy titled Recorgnizing signs and symptoms of abuse/neglect (no date) revealed in part: .Our facility will not condone any form of resident abuse or neglect .neglect is define as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness .inadequate provison or care .caregiver indifference to resident's personal care or needs . The facility Administrator was notified on 11/01/17 at 3:53 p.m. that an IJ was identified and a POR was requested. The POR was submitted by the Administrator on 11/02/17. After several revisions, the final plan of removal was accepted on 11/02/17 at 2:05 p.m. The POR included in part: .On 11/1/2017 the Medical Doctor conducted a pressure injury risk assessment and a skin assessment on Resident #1. , the wound was measured, staged, an order was provided for treatment, The following were the physician orders . Peri-rectal wound: clean with normal saline, pat dry, apply [MEDICATION NAME] gel Daily and PRN after bowel movements .Right ischium and left ischium wounds: clean with normal saline, pat dry, apply Calcium alginate MWF and PRN when soiled as needed .Right ischium and left ischium wounds: clean with normal saline, pat dry, apply Calcium alginate MWF and PRN when soiled . Treatment was initiated as ordered. Appropriate revisions were made to the plan of care to reflect all current pressure injury prevention interventions. The treatment nurse reviewed the revised care plans with all staff scheduled and involved in the care of the resident on 11/1/2017 . Pressure injury risk assessments and skin assessments was completed for all residents on 11/1/2017 by the nursing management team. For those residents at risk, care plans would be reviewed and/or modified to ensure appropriate interventions. The treatment nurse reviewed the revised care plans with all staff involved in the care of at risk residents on 11/1/2017. -The facility policy regarding Pressure Injury Prevention was reviewed 11/1/2017 and updated to include pressure injury risk assessment and skin assessment to be completed upon admission. - Immediate education on wound care policy and procedures were initiated and all nursing staff would be in-serviced by the medical director and/or treatment nurse on the revised facility policy for Pressure Injury Prevention, prevention interventions, wound care, and timely reporting of skin concerns as well as initiating wound care orders or PRN orders when the wound care nurse is not available, also the in-service will include proper admission assessment process for patient so patient would not miss any orders upon admission. The in-service started 11/1/2017 and will be continue until all nursing staff are educated. No nurse staff will be reporting to duty without receiving the in-service for the above concerns. An in-service for all CNA includes but not limited to understand basic wound care, application of barrier cream , communication with nurses on any abnormal skin conditions such as redness, bruising , rashes etc., Understanding the different pressure points and the effectiveness of patient turning. Initiated 11/1/17 and will continue until all staff are in serviced no staff will report to work without receiving the in-service. -A wound care nurse will be schedule on daily (biases), to assist and treat all patients with wounds and all new admission. -An interim meeting with QA committee including our medical director and the wound care physician was conducted on the first of November 2017 to update polices and wound care practices . On 11/02/17 at 9:28 a.m. the Administrator requested a meeting with the survey team. The Administrator, Physician B, Physician C, NP B, the MDS Coordinator, and ADON A attended, along with three surveyors. The facility presented copies of texts regarding Resident #11, but they were all dated prior to the resident's re-admission to the facility on [DATE]. In an interview during the above meeting, Physician B said they were familiar with Resident #11. Physician B said they had tried various treatments, including [DEVICE] for the resident. She said the resident was non-compliant. In an interview during the above meeting Physician C said Resident #11 was non-compliant, and that he removed dressings himself. He said the resident would not turn himself either. In an interview during the above meeting NP B said the resident would remove the wound dressings. When the surveyor asked for documentation or care plan to address those issues including non-compliance, the two Physicians and the NP offered no explanation. During further interview on 11/2/17 at 9:30 am the Administrator said that the wound care nurse (LVN Q) conducted wound care for the resident but did not know how to document it in the computer. When asked why she didn't write a note instead of using the computer, no answer was provided. In an interview during the above meeting, Physician B said the nurse on duty was responsible to make sure the wounds were dressed. In an interview with the Administrator on 11/2/17 at 2:42 pm he said that he believe some of the reasons why this IJ happened is because the previous wound care nurse was in a car accident after the hurricane and he did not return. He said the previous DON was carrying everything on her shoulders. He said he informed her of the problems and the DON decided to eliminate the wound care nurse position and let the floor nurses do the wound care for the residents. In the meantime, he wanted to offer the wound care positon to another nurse, but wanted to hire somebody to cover her position before promoting her. While all the changes were happening, he believes some wound care treatments were not covered. The facility was monitored for the implementation of the plan from 11/2/17 to 11/6/17 with the following results: Record review of the Skin Assessments provided by the facility on 11/02/17 at 2:40 p.m. revealed assessments only for 31 of the 46 residents. One of the residents had two Skin Assessments from two different nurses, both dated 11/01/17. The two assessments were completely different from the other. Further monitor revealed all assessments completed as of 11/6/17 in the morning. Record review of the In-service logs provided revealed 13 staff members had been in-serviced on 1) Preventing pressure Ulcers/Turn Clock and 2) Preventative Skin Care, as of 11/3/17. Eight Staff members had been in-serviced on Wound Documentation, as of 11/3/17. Record review of continued in-servicing on 11/6/17 at 10:00 am revealed 17 additional staff members were in-serviced on wound assessment and documentation and 15 additional staff member were in-serviced on preventing pressure ulcers/turn clock. Interviews with nurses and CNAs during the monitoring revealed understanding of the wound care policy. The residents with Skin breakdown were observed during the monitoring and no concerns were observed. In an interview on 11/04/17 at 1:20 p.m. with the DON, she said she had only been the DON since 10/28/17. When asked what contributed to the IJ, she said the nurses were not aware of what needed to be done, and that there was no follow-through. On 11/06/17 at 10:47 am, the Administrator was informed the IJ was lowered. However, the facility remained out of compliance at a severity level of potential for more than actual harm with a scope identified as pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. According to the list provided by the facility there were 5 residents with skin breakdown.