Every finding on record at Cuero Nursing and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #39) reviewed for incontinence care. CNA-B used multiple passes with the same wipe while cleaning the Resident #39'sgenital area on 01/21/2026. This failure could place residents at risk for cross contamination and the development of new or worsening urinary tract infections.The findings included: Record review of Resident #39's face sheet, dated 01/23/2026, revealed Resident #39 was a [AGE] year-old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnosis of end stage renal disease (when kidneys no longer function well enough to meet a body's needs). Record review of Resident #39's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 8 out of 15, which indicated the resident had moderate cognitive impairment, and the resident was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to chair to bed transfer and Not attempted due to medical condition or safety concerns to toilet transfer. Further record review of the MDS indicated Resident #39 was always bladder and bowel incontinent. Record review of Resident #39's comprehensive care plan, dated 10/30/2025, The resident has functional incontinence of bladder and bowels related to impaired cognition and decreased mobility. For intervention - Clean peri-area with each incontinence episode. Observation on 01/21/2026 at 4:37 p.m. revealed CNA-B washed her hands with water, put on gloves and gown, opened the old and dirty brief of Resident #39, then cleaned the resident's genital area. When CNA-B cleaned Resident #39's genital area (the penis), the CNA had multiple pass with the same wipe, and then CNA-B turned Resident #39 on his side and cleaned the resident's anal area. Further observation revealed that CNA-B changed her gloves after sanitizing her hands and put a new and clean brief under the resident, then closed the brief. During an interview on 01/21/2026 at 4:43 p.m. CNA-B stated she had multiple pass with the same wipe when cleaning Resident #39's penis area. CNA-B said she was nervous, so she forgot to use new disposable wipe with each stroke when cleaning Resident #39's genital areas. CNA-B stated she should have used new wipe with each stroke, instead of multiple pass, to prevent possible infection. During an interview on 01/22/2026 at 11:40 a.m. DON stated CNA-B should have used new wipe with each stroke when cleaning Resident #39's genital area to prevent possible urinary tract infection. Record review of the facility policy, titled Perineal Care, dated 10/24/2022, revealed . 12. Males. G. Cleans the shaft of the penis, using downward strokes toward the scrotum. Use separate section of washcloth or new disposable wipe with each stroke.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 2 medication carts (200 & 400 hall nursing cart and 500 hall nursing cart) of 5 medication carts reviewed for medication storage. 1. In the nurse cart in hall 200 & 400, one insulin bottle (Novolin) of Resident #8 was opened, but there was no open date on the label of the insulin bottle. 2. The nurse cart in hall 500 was unlocked unattended while LVN-D was providing intravascular care to Resident #102. This failure could place residents at risk of missing or misuse of drugs by unauthorized personnel and not reach to therapeutic effects.The findings included: 1. Observation nursing cart foe the hall 200 & 400 on [DATE] at 3:29 p.m. revealed there was one bottle of Resident #8's NovoLIN R Injection Solution 100 UNIT/ML inside the. The insulin bottle was opened, but there was no open date on the bottle. During an interview on [DATE] at 3:40 p.m. with LVN-D stated there was one bottle of Resident #8's NovoLIN R Injection Solution 100 UNIT/ML inside the nursing cart in hall 200 & 400, and the insulin bottle was opened, but there was no open date on the bottle. LVN-D said she opened it morning time on [DATE] and forgot to write open date on it. Further interview with the LVN-D said writing open date on the insulin was very important because per the facility policy, they should discard NovoLIN R Injection Solution 100 UNIT/ML after 42 days once it was opened. The nurse said if the insulin bottle did not have open date, facility nurses did not know when they have to discard it, might use it, and it might not have therapeutic effects. During an interview on [DATE] at 11:40 a.m. with DON stated facility nurses should have written open date on the insulin bottle of Resident #8's NovoLIN R Injection Solution 100 UNIT/ML because per the facility policy, they should discard NovoLIN R Injection Solution 100 UNIT/ML after 42 days once it was opened, and if facility nurses used the expired insulins, the resident might not have therapeutic effects. 2. Observation on [DATE] at 2:55 p.m. revealed LVN-D opened the nurse cart in hall 500, took out Resident #102's intravenous medication and equipment, entered Resident #102's room, and closed the room door without locking the nurse cart. The nurse cart in hall 500 was unlocked unattended in the 500-hall way while LVN-D was administrating IV medication to Resident #102. During an interview on [DATE] at 3:00 p.m. with LVN-D stated she forgot to lock the nurse cart and left the cart to be unlocked while she was administering IV medication to Resident #102. LVN-D said it was her mistake, and she should have locked the cart all the time to prevent missing or misuse of drugs by unauthorized personnel. During an interview on [DATE] at 11:40 a.m. with DON stated facility nurses should have locked their carts all the time for safety and to prevent missing or misuse of drugs by unauthorized personnel. Record review of the facility policy, titled Storage and expiration - Diabetes injections, undated, revealed discard the insulin Novolin R Vial after 42 days once it was opened. Record review of the facility policy, titled Medication Administration, revised [DATE], revealed . p. during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #41) of 8 residents reviewed, in that: Resident #'41s personal refrigerator located in her room was observed on 01/20/2026. There were three small plastic containers inside the refrigerator, with no dates and no labels on the plastic containers. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #41's face sheet, dated 01/23/2026, reflected the resident was an 88-years-old female and was initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroy memories and other important mental functions), dementia (loss of memory and thinking ability), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), and hypertension (high blood pressures). Record review of Resident #41's Quarterly MDS assessment, dated 12/22/2025, reflected the resident's BIMS score was 7 out of 15 which indicated the resident had severe cognitive impairment, and the resident was Setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating and Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for sit to stand and chair to bed transfer. Record review of Resident #41's comprehensive care plan, dated 11/12/2025, revealed the resident had The resident is at risk for nutritional problems related to impaired cognition and poor dentition. She is at risk for malnutrition and for interventions - Provide, serve diet as ordered. Observe intake and record every meal. Observation on 01/20/2026 at 11:23 a.m. revealed Resident #41 was on the bed and sleeping in her room. There was a personal refrigerator in the room, and inside the refrigerator there were three small plastic containers with food, but no dates and no labels on the containers. During an observation and interview on 01/20/2026 at 12:00 p.m. with RN-C stated Resident #41's refrigerator in her room had three small plastic containers with food, but the containers were not dated and labeled. RN-C said that the food in three small plastic containers looked like salad dressings. The facility night nurses were supposed to check it every day and write dates and labels to prevent possible food-born illness. During an interview on 01/22/2026 at 11:40 a.m. the DON stated facility night nurses were responsible for overseeing Resident #41's personal refrigerator and also responsible for monitoring it daily. The DON stated the resident might have illness due to food. Record review of the facility policy, titled Resident Refrigerators, dated 07/03/2023, revealed . 4. Residents and staff shall comply with safe food handling and storage principles: b. leftovers shall be dated upon receipt and discard within three days.

Based on observation, interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #6 and #102) out of 6 residents reviewed for medical records. 1. ADON LVN-E did not document on Resident #6's treatment administration record on 01/09/2026 after providing wound care to the resident. 2. The facility nurse did not document on Resident 102's medication administration record on 01/17/2026 regarding the resident was out on pass. This failure placed residents at risk for missed treatment and medications which could result in decline in health and well-being.Findings included: 1. Record review of Resident #6's face sheet, dated 01/23/2026, revealed the resident was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), pressure ulcer of left ankle-stage 4 (injuries to the skin and the tissue below skin that are due to pressure on the skin for a long time), hemiplegia and hemiparesis (partial weakness that occurs on one side of the body), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #6's Quarterly MDS assessment, dated 01/20/2026, revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment and was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to most activities of daily life such as sit to stand, chair-to-bed, and toilet transfer and had unhealed pressure ulcer and moisture associated skin damage in Section M (Skin Condition). Record review Resident #6's comprehensive care plan, dated 01/16/2026, revealed that the resident had the care plan of PRESSURE ULCER/INJURY: the resident has impaired skin integrity related to Unstageable ulcer to left lateral Ankle and Moisture Associated Skin Damage to right gluteus (bittock). For intervention - Apply treatment as ordered. Record review of Resident #6's physician order, dated 12/26/2025, revealed the resident had the order of Right buttocks Moisture Associated Skin Damage - Cleanse with wound cleanser, pat dry, apply Zinc Oxide & cover with border foam dressing QOD (every other day) & as needed if soiled or dislodged. Record review of Resident #6's treatment administration record from 01/01/2026 to 01/31/2026 revealed Right buttocks Moisture Associated Skin Damage - Cleanse with wound cleanser, pat dry, apply Zinc Oxide & cover with border foam dressing QOD (every other day) & as needed if soiled or dislodged was scheduled every other day. Further record review of the treatment administration record revealed there was blank on 01/09/2026, which was scheduled for the wound care. During an interview on 01/23/2026 at 8:43 a.m. with ADON LVN-E said the facility wound care nurse usually provided wound care to Resident #6, but ADON LVN-E provided the wound care on 01/09/2026 because the facility wound care nurse left early from the facility on 01/09/2026 due to private reasons. ADON LVN-E said she forgot to document it on the treatment administration record, it was her mistake, and the resident's treatment administration record should have been accurate to prevent providing incorrect wound care to the resident. 2. Record review of Resident #102's face sheet, dated 01/23/2026, revealed Resident #102 was a [AGE] year-old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnoses of urinary tract infection (bacteria enter the urinary tract through the urethra and begin to spread in the bladder), anemia (A condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), hepatitis C (viral infection that causes liver swelling, called inflammation). Record review of Resident #102's admission MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15, which indicated the resident had moderate cognitive impairment, and the resident had intravenous medications as ordered in Section O (Special Treatments, Procedures, and Programs). Record review of Resident #102's comprehensive care plan, dated 01/19/2026, revealed the resident had the care plan of The resident potential fluid deficit related to use of IV fluids in hospital and current use of IV antibiotics. For intervention - Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #102's physician order, dated 01/15/2026, revealed Meropenem Intravenous Solution Reconstituted 1 Gram (Meropenem) Use 1 gram intravenously every 8 hours related to URINARY TRACT INFECTION until 02/03/2026. Record review of Resident #102's medication administration record from 01/01/2026 to 01/31/2026 revealed Meropenem Intravenous Solution Reconstituted 1 Gram (Meropenem) Use 1 gram intravenously every 8 hours related to URINARY TRACT INFECTION until 02/03/2026 was scheduled 7:00 am, 3:00 pm, and 11:00 pm. Further record review of the medication administration record revealed there was a blank on 01/17/2026 at 3:00 pm. Observation on 01/21/2026 at 2:55 p.m. revealed the facility nurse administrated Meropenem Intravenous Solution Reconstituted 1 Gram (Meropenem) to Resident #102 via IV. During an interview on 01/23/2026 at 9:31 a.m. with DON said Resident #102 was out on pass on 01/17/2026 at 3:00 pm for the resident's appointment as evidence by the facility in and out log. Further interview with DON said the facility nurse should have documented on the medication administration record as 1 which mean 1=out on pass without meds per the direction. The facility nurse should not leave blank on the medication administration record because the resident's medication administration record should have been accurate to prevent providing incorrect dosage to the resident, and it was the facility nurses' mistake. The DON had responsibility to oversee residents had accurate medication administration records. Record review of the facility policy, titled Documentation in Medical Record, dated 10/24/2022, revealed . 3. Principles of documentation include, but are not limited to. b. documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and /or responses to care. C. documentation shall be timely and in chronological order.

Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 19 residents (Resident #3) reviewed for assessments: Resident #3's admission MDS, dated [DATE], identified the resident had urinary indwelling catheter. This failure could place residents at risk for inadequate care due to inaccurate assessments.The findings included: Record review of Resident #3's face sheet, dated 01/23/2026, revealed the resident was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses of hypertensive chronic kidney disease (high blood pressure can constrict and narrow the blood vessels in your kidneys, which reduces blood flow and stops the kidneys from working well regarding removing all wastes and extra fluid from the body) and retention of urine (blockage that partially of fully prevents urine from leaving the bladder or urethra or bladder not being able to maintain a strong enough force to expel all the urine). Record review of Resident #3's admission MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognitive was intact. Section H (Bladder and Bowel), the resident had indwelling urinary catheter. Question H0300 of Urinary Continence? was coded to 1- occasionally incontinent, Record review of Resident #3's comprehensive care plan, dated 12/22/2025, revealed that Resident #3 has an indwelling catheter related to urinary retention. For intervention, the resident has indwelling urinary catheter - Position catheter bag and tubing below the level of the bladder and away from entrance room door and check tubing for kinks each shift. Observation on 01/20/2026 at 2:57 p.m. revealed Resident #3 had an indwelling urinary catheter, and the catheter bag was secured at the bed frame. During an interview on 01/23/2026 at 9:04 a.m. MDS nurse LVN-A stated Resident #3's admission MDS, dated [DATE], indicated the resident had an indwelling urinary catheter. MDS Nurse LVN-A stated question H0300 of Urinary Continence? should have been coded 9 - not rated because Resident #3 had an indwelling urinary catheter. The MDS nurse LVN-A said coding accurately was a MDS nurse's responsibility, and inaccurate MDS assessments might result in improper care to the resident, and the facility did not have policy for MDS accuracy, but following CMS's RAI Manual guidelines. Record review of CMS's RAI version 3.0 Manual, titled H0300: Urinary Continence: Prognosis, paged H-10, dated 10/2025, revealed Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter, condom catheter, ostomy, or no urine output (e.g., is on chronic dialysis with no urine output) for the entire 7 days.

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 to help prevent the development and transmission of infections involving 1 of 3 staff (CMA B) reviewed for infection control, in that: The facility failed to ensure CMA B cleaned the blood pressure cuff between Resident #6 and Resident #7. These deficient practices could place residents at-risk for infections. The findings included: During an observation on 07/09/2025 at 02:36 p.m., CMA B was observed taking Resident #6's blood pressure prior to administering medications to the resident. CMA B returned to her medication cart and placed the blood pressure cuff on the cart. CMA B did not sanitize the blood pressure cuff. CMA B then went and took Resident #7's blood pressure with the same cuff. CMA B again returned to her medication cart and placed the blood pressure on top of her cart. CMA B again did not sanitize the blood pressure cuff. During an interview on 07/09/2025 at 02:49 p.m., CMA B stated she knew she was forgetting something during her medication administration observation. She revealed she was supposed to wipe the blood pressure cuff after and between each resident. She stated the nursing facility had provided training that reviewed these procedures. She stated wiping the cuff between residents was for sanitation reasons, to stop the spread of germs. During an interview on 07/10/2025 at 02:53 p.m., the DON revealed staff were to take blood pressure readings prior to administering blood pressure medications and the staff were to disinfect the blood pressure cuff between each resident. She stated disinfecting the cuff was for infection control purposes. Record review of facility policy, Infection Prevention and Control Program, date implemented 05/13/2023, reflected under Policy Explanation and Compliance Guidelines, 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. and 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing, administering, and timely documentation of medications given, to meet the needs of each resident for 2 of 17 residents (Resident #3 and Resident #4) reviewed for pharmacy services. 1. CMA A failed to ensure medications were signed out as given to Resident #3 after administration, and not before they were given. 2. LPN H failed to reconcile Resident #4's documented penicillin (antibiotic) allergy with the physician's order for amoxicillin (antibiotic) before it was scheduled for administration on 06/29/2025. These failures could place residents at risk for loss of prescribed medications, drug diversion, and not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications. Findings included: 1. Record review of Resident #3's admission Record reflected a [AGE] year-old male, with an original admission date of 05/29/2025 and a re-admission date of 06/09/2025. Record review of Resident #3's Medical Diagnosis EMR tab, undated and reviewed on 07/10/2025, reflected Resident #3 had diagnoses including high blood pressure, pain in the right knee, constipation, stiffness in the right knee, and low back pain. Record review of Resident #3's MDS dated [DATE] documented a BIMS score of 12 out of 15, which suggested a moderate cognitive impairment (some trouble with memory, thinking issues, and making decisions that affected daily life). Record review of Resident #3's Care, undated and assessed on 07/10/2025, reflected the following focus, The resident has an AOL self-care, initiated on 05/30/2025 and revised on 06/25/2025. The interventions included staff assistance with showering, dressing, transferring, and monitoring for any changes. Record review of Resident #3's Order Summary Report dated 07/09/2025 reflected the following orders: Baclofen Oral Tablet (Baclofen) Give 20 mg by mouth three times a day for muscle spasm, dated 06/09/2025. Docusate Sodium Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth two times a day forConstipation dated 06/09/2025. Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day for NERVE PAIN, dated 06/09/2025. hydrALAZINE HCI Oral Tablet 100 MG (Hydralazlne HCI) Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (110) **Give 2-50mg tablets to equal 100mg until supplyexhaust**, dated 06/12/2025. oxyCODONE HCI Oral Tablet 20 MG (Oxycodone HCI) Give 1 tablet by mouth every 6 hours for PAIN, dated 06/09/2025. During an observation on 07/08/2025 at 05:00 p.m., CMA A pulled and poured Resident #3's medications, . CMA A then proceeded to sign out all medications as given, which turned each medication color on the electronic medication administration record from yellow to green, CMA A then went into Resident #3's room where he took all of the medications. During an interview on 07/08/2025 at 05:10 p.m., CMA A stated that she administered Resident #3's and indicated she signed the medications out as given before Resident #3 took them and that she was trained that way two years ago by a CMA who no longer worked in the facility and had not had any training since that time. CMA A revealed that when it was time for medications to be given, the color on the screen appeared yellow, and that when they were signed as given the medications turned green. Record review of the facility's policy titled Medication Administration dated 10/01/2019, reflected that for Documentation (including electronic) A. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. 2. Record review of Resident #4's admission Record, dated 07/09/2025, reflected an [AGE] year-old female. She was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #4's Medical Diagnosis EMR tab, undated and accessed on 07/09/2025, reflected Resident #4 had diagnoses which included vascular dementia (brain damage typically caused by multiple strokes), cerebral infarction (a disruption in the brain's blood flow), and type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel) with hyperglycemia (high sugar levels in the blood). Record review of Resident #4's Quarterly MDS, dated [DATE] with observation end date of 07/02/2025, reflected Resident #4 had a BIMS score of 8, which indicated she was mildly cognitively impaired. She was documented as having taken an antibiotic during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #4's EMR Allergy tab, accessed on 07/09/2025, reflected Resident #2 had an allergy to Penicillin, dated 11/18/2019, with unknown severity. Record review of Resident #4's Care Plan, undated and accessed 07/09/2025, reflected the following focus, [Resident #4] is at risk for allergic reaction as she is allergic to: PENICILLIN & SULFA ANTIBIOTICS, date initiated 12/07/2024 and revised 02/05/2025. The interventions included, [NAME] chart with allergies, Notify MD of any accidental ingestions of medications/foods on allergy list, and Notify pharmacy of allergies, all initiated on 12/07/2024. Record review of Resident #4's Order Audit Report, dated 07/09/2025, reflected Amoxicillin Oral Tablet 500 MG (Amoxicillin) Give 1 tablet by mouth two times a day for UTI for 5 Days, was verbally ordered by MD D on 06/29/2025 at 04:59 p.m. The order was created by LPN H on 06/29/2025 at 05:01 p.m. The Signature Type was noted as Pending. The order was last revised on 06/29/2025 at 07:34 p.m. The Administrative Order Summary noted LPN E documented the order was discontinued on 06/30/2025 at 07:48 a.m. by MD C with the reason DC MEDICATION D/T ALLERGIC REACTION. Record review of Resident #4's MAR (Medication Administration Record), dated 06/01/2025 - 06/30/2025 and printed on 07/09/2025, reflected: Amoxicillin Oral Tablet 500 MG (Amoxicillin) Give 1 tablet by mouth two times a day for UTI for 5 Days, start date 06/29/2025 at 06:00 p.m. and d/c date 06/30/2025 at 07:48 a.m., was administered one time, on 06/29/2025 at *6p-1, by LPN G. Record review of Resident #4's Progress Notes, created date range 06/26/2025 to 07/09/2025 and printed on 07/09/2025, reflected: - a NURSING Nurse Note, dated 06/29/2025 at 05:01 p.m., by LPN H reflected This nurse notified [MD D] of the UA and C&S results, and he ordered Amoxicillin Oral Tablet 500 MG [sic] Give 1 tablet by mouth two times a day for UTI for 5 Days.- a NURSING Nurse Note, dated 06/29/2025 at 05:01 p.m., by LPN H reflected The system has identified a possible drug allergy for the following order: Amoxicillin Oral Tablet 500 MG (Amoxicillin) [sic] Give 1 tablet by mouth two times a day for UTI for 5 Days.- a NURSING Nurse Note, dated 06/30/2025 at 01:22 a.m., by LPN G reflected INITIAL DOSE OF ABT AMOXICILLIN 500MG 1 TAB PO BID X5 DAYS FOR UTI, RES TOLERATED MEDICAITON WELL. ENCOURAGED RESIDENT TO OMCREASE [sic] WATER INTAKE. NO CONCERNS VOICED.- a NURSING Nurse Note, dated 06/30/2025 at 07:43 a.m., by LPN E reflected RESIDENT IS PRESCRIBED PO AMOXCILLIN [sic] 500MG 1 TAB BID X 5 DAYS FOR UTI, WITH INITIAL DOSED [sic] OF ADMINISTRATION LAST NIGHT; HOWEVER, RESIDENT HAS ALLERGIES TO PENICILLIN. RES AOX 4, ABLE TO ANSWER QUESTIONS CLEAR AND APPROPRIATELY. V/S OBTAINED.NO S/S OF ANY ADVERSE REACTION OR COC. NO VERBAL CONCERNS MENTIONED.MORNING DOSE OF ABT IS HELD. NOTIFIED [MD C], GIVEN NEW ORDER TO DC PO AMOXICILLIN.NOTIFIED [Resident #4's Representative].- a Change of Condition, dated 06/30/2025 at 07:43 a.m., by LPN E reflected MED ERROR: PO AMOXICILLIN GIVEN, WHOM HAS ALLERGIES TO PENICILLIN, started 06/30/2025, since started it has gotten: [response not selected]. - a NURSING- Nurse Note, dated 07/01/2025 at 02:32 a.m., by LPN I reflected Day 1 F/U med error receiving ABT Amoxicillin x 1 dose. Resident is allergic to ABT. No adverse reactions noted. No redness, rash or swelling noted. Resident is able to voice needs.- a NURSING- Nurse Note, dated 07/01/2025 at 06:41 a.m., by LPN E reflected DAY 1 F/U MED ERROR OF RECEIVING ABT AMOXCILLIN [sic] X 1.NO S/S OF ANY ADVERSE REACTION NOTED. NO VERBAL CONCERNS MENTIONED. - a NURSING- Nurse Note, dated 07/02/2025 at 02:35 a.m., by LPN I reflected Day 2 F/U FOR med error received ABT resident has an allergy to. No adverse reactions noted. No complaints of discomfort voiced.- a NURSING- Nurse Note, dated 07/02/2025 at 07:09 p.m., by LPN J reflected DAY 2 F/U FOR MED ERROR OF RECEIVING ABT AMOXCILLIN [sic]. NO ADVERSE REACTIONS NOTED. NO C/O PAIN OR DISCOMFORT NOTED. - a NURSING- Nurse Note, dated 07/03/2025 at 11:28 a.m., by LPN J reflected DAY 3 F/U FOR MED ERROR OF RECEIVING ABT AMOXCILLIN [sic]. NO ADVERSE REACTIONS NOTED. NO C/O PAIN OR DISCOMFORT NOTED. Record review of facility report, Incidents By Incident Type, date range 04/08/2025 to 07/08/2025 and printed 07/08/2025, reflected Resident #4 noted under Medication Error Incidents on 06/30/2025 at 07:43 a.m. During an interview on 07/10/2025 at 11:10 a.m., Resident #4 revealed she was aware the facility changed her antibiotic order after 1 dose of the oral antibiotic to an antibiotic given intravenously, through her vein. She revealed she had not experienced any rashes, upset stomach, or other side effects from the oral antibiotic medication. Resident #4 did not mention a prior allergic reaction to the oral antibiotic. During an interview on 07/10/2025 at 12:17 p.m., MD C revealed he was the facility medical director. He revealed he believed the amoxicillin was ordered after the bacteria culture result was received and relayed to the on-call physician, MD D. He revealed MD D ordered the amoxicillin, but MD C stated he was not sure if the nurse that relayed the culture result to MD D saw the allergy note on Resident #4's record or relayed the allergy information to MD D. He stated he would say that the allergy information should have been relayed. MD C stated the EMR would have required the nurse to bypass the allergy notification when putting in the order. MD C stated he did not have any concerns regarding Resident #4's impact of the error because Resident #4 had only received one dosage and the facility notified him that she had not experienced any adverse effects. Attempted to interview LPN H on 07/10/2025 at 01:02 p.m., 02:50 p.m., and 05:00 p.m. Missed LPN H's return call on 07/10/2025 at 04:19 p.m. During an interview on 07/10/2025 at 02:53 p.m., the DON revealed the nurse took the amoxicillin order from the doctor and administered the medication without verifying allergies. The DON stated the allergy concern was identified in the morning, the doctor and family were notified, and Resident #4 was put on a 72-hour observation. The DON stated she did not believe Resident #4 was impacted by the error because the resident did not have an adverse reaction to the antibiotic and the doctor changed the antibiotic the next day. The DON stated she was not sure who received the order and did not know if the nurse had discussed the allergy information with the physician. The DON stated the facility medication administration training did cover medication allergies. During an interview on 07/10/2025 at 02:38 p.m., LPN G revealed she did not put in the amoxicillin order for Resident #4 but did administer the medication. She revealed she did not call the physician about the order because she assumed that the staff member that entered the order in the EMR had called the doctor and discussed the order. She revealed she was not aware Resident #4 had any allergies until the next day; however, she did check on Resident #4 during the night and Resident #4 did not have any type of reaction. LPN G revealed part of the facility procedure for receiving and documenting a new medication order was to alert the family and resident about the new medication, and to make sure there were not any adverse reactions to the medication. Record review of facility policy, Medication Administration, date devised 10/01/2019, reflected under Procedure, 1. Preparation.D. 10 Rights of Medication Administration- .10. Right Evaluation- Make sure you check for drug allergies and interactions between different medications. Doctors and pharmacists don't always catch them [sic] and we need to be a third set of eyes.

Based on interviews and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 4 residents (Resident #1 and Resident #4) reviewed for clinical records. 1. CMA A failed to document a progress note following the entry of chart code 5= Hold/See Progress Notes on 06/16/2025 for Resident #1's Metoprolol Tartrate (a blood pressure medication) order. 2. CMA A failed to document progress notes following the entry of chart code 9= Other/See Progress Notes on 07/02/2025 and 07/03/2025 for Resident #5's Olmesartan Medoxomil-HCTZ (a blood pressure medication) order. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Findings included: 1. Record review of Resident #1's admission Record, dated 07/08/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #1's Medical Diagnosis EMR tab, undated and accessed on 07/08/2025, reflected Resident #1 had diagnoses which included alcohol dependence with alcohol-induced persisting dementia (a general term for impaired ability to remember, think, or make decisions), hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body), and muscle wasting and atrophy (shrinking of muscle or nerve tissue). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 12, which indicated he was mildly cognitively impaired. Record review of Resident #1's Order Recap Report, order date: 06/01/2025- 07/31/2025 and printed on 07/08/2025, reflected Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold for sbp<100 dbp< 60 hr <60, order date 11/13/2024, start date 11/14/2024, and end date 07/02/2025. Record review of Resident #1's MAR, dated 06/01/2025 - 06/30/2025 and printed on 07/08/2025, reflected: Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold for sbp<100 dbp< 60 HR <60, start date 11/14/2024 at 06:00 p.m. and d/c date 07/02/2025 at 01:12 p.m., was coded as 5 on 06/16/2025 by CMA A. Vitals entered on 06/16/2025 reflect a blood pressure of 94/62 and pulse of 67. Chart Codes reflect 4=BS/VS Outside of Parameters for Admin and 5=Hold/See Progress Notes. Record review of Resident #1's Progress Notes, dated 06/11/2025 to 06/25/2025, did not reveal a progress note mentioning medication administration or blood pressure values. During an interview on 07/10/2025 at 11:09 a.m., Resident #1 revealed he had received his medications on time and had not observed any issues with his medication administration. He revealed the staff check his blood pressure twice a day and he knew his blood pressure values go up and down due to his heart issues. He stated he had not had any issues with his blood pressures or blood pressure medication. 2. Record review of Resident #5's admission Record, dated 07/08/2025, reflected an [AGE] year-old female. She was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #5's Medical Diagnosis EMR tab, undated and accessed on 07/08/2025, reflected Resident #5 had diagnoses which included unspecified dementia, polyneuropathy, and hypertension. Record review of Resident #5's Annual MDS, dated [DATE], reflected Resident #5 had a BIMS score of 9, which indicated she was mildly cognitively impaired. Record review of Resident #5's Order Summary Report, dated on 07/08/2025, reflected Olmesartan Medoxomil-HCTZ Oral Tablet 40-12.5 MG (Olmesartan Medoxomil-Hydrochlorothiazide) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10), order date 07/01/2025 and start date 07/02/2025. Record review of Resident #5's MAR, dated 07/01/2025 - 07/31/2025 and printed on 07/08/2025, reflected: Olmesartan Medoxomil-HCTZ Oral Tablet 40-12.5 MG (Olmesartan Medoxomil-Hydrochlorothiazide) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10), start date 07/02/2025 at 08:00 a.m., was coded as 9 on 07/02/2025 and 07/03/2025 by CMA A. Chart Codes reflect 9=Other / See Progress Notes. Chart Codes did not reflect a code description for On order. Record review of Resident #5's Progress Notes, printed on 07/08/2025 and dated effective date range: 06/08/2025 to 09/09/2025 and created date range: all created; did not reveal a progress note entered after 07/01/2025. During an interview on 07/10/2025 at 02:13 p.m., Resident #5 revealed she was administered her medications generally at the same time each day. She stated she took medication for blood pressure and the staff checked her blood pressure twice a day. She stated her blood pressure was different at different times a day. During an interview on 07/10/2025 at 12:51 p.m., CMA A revealed she did not recall entering a code for Resident #1's blood pressure medication on 06/16/2025, but thought she most likely held his medication because his blood pressure was outside of parameters. She stated she would have entered an out of parameters code in the MAR if Resident #1's blood pressure values were outside the order's hold parameters. CMA A revealed she did recall Resident #5's blood pressure medication not being in stock when the order started. She stated the nurse told her they (the nursing staff) would start administering the medication once the medication was in stock. She revealed she recalled putting an on order code in the eMAR. She stated when she clicked No for administered, the computer will provide prompts, and she could select on order. She stated she selected on order for those days. During an interview on 07/10/2025 at 02:53 p.m., the DON revealed she believed the MAR had a code for when a medication was not available. She revealed the staff were to go to the nurse when a medication was not available, and the nurse was to order the medication or take it out of the facility's medication inventory. The DON stated she believed the eMAR was supposed to generate a progress note when a staff member selects see progress note, and the staff were to put specifics of the medication administration into the progress note. The DON stated she was unsure why there would not have been corresponding progress notes to see progress note codes in the MAR. The DON stated the impact of not having the corresponding progress note would be that the nurse managers would have to search for the information and/or speak directly with the staff member that entered the see progress note to determine what meds were not given and why. Record review of facility policy, Medication Administration, date devised 10/01/2019, reflected under Procedure, 4. Documentation (including electronic) . F. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time.An explanatory note is entered.G. If an electronic MAR system is used, specific procedures required for.documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. Record review of facility policy, Documentation in Medical Record, date implemented 10/24/2022, reflected under Policy Explanation and Compliance Guidelines: . 3. Principles of documentation include, [sic] but are not limited to: .b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on interviews and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 2 of 5 (Resident #1 and Resident #2) residents reviewed for quality of care. 1. The facility failed to follow policy and Resident #1's care plan intervention to conduct weekly skin assessments for 1 of 14 (week of 05/09/2025) weeks reviewed. 2. The facility failed to follow policy and conduct a quarterly fall risk assessment for Resident #2 scheduled on 06/26/2025. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The findings included: 1. Record review of Resident #1's admission Record, dated 07/08/2025, reflected a [AGE] year-old male, admitted to the facility on [DATE]. Record review of Resident #1's Medical Diagnosis EMR tab, undated and accessed on 07/08/2025, reflected Resident #1 had diagnoses which included alcohol dependence with alcohol-induced persisting dementia (a general term for impaired ability to remember, think, or make decisions), hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body), and muscle wasting and atrophy (shrinking of muscle or nerve tissue). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 12, which indicated he was mildly cognitively impaired. He was documented as received a pressure reducing device for his bed under skin and ulcer/injury treatments. Record review of Resident #1's Care Plan, undated and accessed 07/08/2025, reflected Resident #1 had a focus for skin integrity, noted as at risk for impaired skin integrity related to decreased mobility, smoker, hx of alcohol dependence., date initiated and revised 10/01/2024. His interventions included, Conduct skin inspections / examinations weekly and as needed. Document findings., date initiated 10/01/2024. Record review of Resident #1's [EMR] Skin & Wound- Total Body Skin Assessments, located under the EMR Forms tab, reflected an assessment was not recorded in the medical record for the week of 05/09/2025. His prior [EMR] Skin & Wound- Total Body Skin Assessment was dated 05/02/2025 and his following assessment was dated 05/12/2025. Record review of Resident #1's Progress Notes, dated 05/02/2025 to 05/14/2025, did not reveal a progress note mentioning skin conditions, appointments, passes, or transfers/discharges. Record review of facility document, Daily Nursing Schedule, dated 05/09/2025 and 05/10/2025, revealed LPN E was scheduled as the nurse for Resident #1's hall from 06:00 a.m. to 06:00 p.m. LPN E had initialed next to her name on both dates. During an interview on 07/10/2025 at 11:09 a.m., Resident #1 revealed he had not experienced any skin issues or wounds since his admission to the facility. Resident #1 revealed he could not recall a skin assessment having been missed. During an interview on 07/10/2025 at 02:53 p.m., the DON revealed the [EMR] Skin & Wound- Total Body Skin Assessment was to be completed every 7 days. She stated the assessment was assigned by hall and the treatment nurse was responsible for completing those assessments. She revealed the impact of a missed skin assessment might be that a skin issue was not identified timely and could develop into something worse. During an interview on 07/10/2025 at 03:13 p.m., LPN F revealed she had worked for the facility since around November or December of 2024, but transitioned to the treatment nurse position in late May 2025. She revealed she was not the treatment nurse during the week of 05/09/2025. She stated it was possible Resident #1 was out for an appointment or something, which caused him to miss his skin assessment. She stated the charge nurses were completing the weekly skin assessments between the time the prior full-time treatment nurse left and she transitioned into the position, no more than a week. She revealed since starting the treatment nurse position, she was responsible for completing the weekly skin assessments. She revealed Resident #1 had not experienced any skin issues other than dry skin since she had started completing the weekly skin assessments. During an interview on 07/10/2025 at 03:24 p.m., LPN E revealed she did not recall Resident #1's skin assessment for the week on 05/09/2025. She stated she did not know if the assessment was not done or just not marked as done. She stated that at the time, the system for completing the skin assessments was being changed. She stated the nurses could go to the forms tab in the EMR and see if there were any resident assessments due that day or past due. She stated she was unsure what would have been due on 05/09/2025 or 05/10/2025 for Resident #1. She revealed she was not aware of Resident #1 having had any skin issues. She stated Resident #1 was very independent and would tell the staff if he had any concerns. She stated that if an assessment was missed, the staff would have to go back and assess him to ensure they didn't miss any changes. Record review of facility policy, Skin Assessment, date implemented 04/24/2025, reflected, Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. 2. Record review of Resident #2's admission Record, dated 07/09/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 07/09/2025, reflected Resident #2 had diagnoses which included diastolic (congestive) heart failure (CHF; a long-lasting condition resulting from the loss of the heart's ability to relax between heartbeats reducing the amount of blood that can enter the heart), unsteadiness on feet, (osteo)arthritis (OA; a joint disease where the cartilage that cushions the ends of bones wears down over time leading to pain, stiffness, and a loss of flexibility), gout (inflammatory arthritis), polyneuropathy (a disorder that damages the peripheral nerves, which control the movement of the arms and legs), and muscle wasting and atrophy. Record review of Resident #2's Quarterly MDS, dated [DATE], reflected Resident #2 had a BIMS score of 12, which indicated he was mildly cognitively impaired. He was documented as having had no falls since admission/entry or reentry or the prior assessment. Record review of Resident #2's Care Plan, undated and accessed 07/09/2025, reflected Resident #2 had the following focuses and interventions:- [Resident #2] has ADL self-care performance deficit r/t generalized weakness & debility. DX: CHF, OA and Gout. He has poor balance., date initiated 05/10/2024 and revised on 07/06/2025. Interventions included, Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.- [Resident #2] has limited physical mobility related to weakness and debility. DX: CHF, Gout, Neuropathy & OA. Non-ambulatory., date initiated 05/08/2024 and revised on 07/06/2025. Interventions included, Monitor/document/report PRN any s/sx of immobility: contractures [a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff] forming or worsening, thrombus [blood clots within the blood vessels that reduces blood flow] formation, skin-breakdown, fall related injury, date initiated 05/08/2024. - [Resident #2] is at risk for falls related to impaired cognition, balance and safety awareness. He has impaired vision., date initiated and revised 05/10/2024. His interventions included, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs., date initiated 05/08/2024. Record review of Resident #2's EMR Forms tab, accessed on 07/09/2025, reflected a Nursing- Fall Risk Evaluation V-1 was due 06/26/2025, with schedule frequency noted as Schedule Completion of Fall Risk- admission / Quarterly. The most recent Nursing- Fall Risk Evaluation V-1 was dated 03/26/2025. Record review of Resident #2's Nursing- Fall Risk Evaluation- V 1, dated effective date 03/26/2025, reflected the reason for the evaluation was quarterly. The resident was categorized as high fall risk with a score of 15. Record review of Resident #2's Progress Notes, created date range 03/26/2025 to 07/09/2025, did not reveal a progress note mentioning Resident #2's fall risks between 06/26/2025 and the last documented progress note, dated 07/02/2025. Attempted interview on 07/10/2025 at 01:33 p.m. Resident #2 was not able to vocalize response, but indicated he did not want to be interviewed. He indicated he did not feel well and wanted to see the nurse. During an interview on 07/10/2025 at 02:53 p.m., the DON revealed the Nursing- Fall Risk Evaluations was to be completed upon admission, re-admission, quarterly, and if there is a significant change or incident, it may trigger to be completed. She stated the schedule for the evaluations was per policy. She stated the evaluations were assigned to the charge nurses, but the MDS nurses may also complete them. She stated the evaluations will automatically populate in the EMR when they are due. She stated the nurses are notified when they have a quarterly assessment to complete. She revealed the impact of a missed assessment or evaluation might be that the staff do not catch a change in the resident's well-being. During an interview on 07/10/2025 at 03:24 p.m., LPN E revealed the nurses are typically notified by the MDS nurses when their resident quarterlies are due, and the notification would include what shift was assigned to do them. She revealed the assignments were separated by shift, so each shift had only so many assessments/evaluations to do during their shift. Record review of facility policy, Fall Prevention Program, date implemented 08/15/2022, reflected, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Policy Explanation and Compliance Guidelines: . 4. Low Risk Protocols: . g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. 5. High Risk Protocols: . b. Provide additional interventions as directed by the resident's assessment.

Based on observation, interview and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. Cook C failed to cover a pan of wheat rolls to prevent the rolls from being contaminated. Cook D failed to ensure all foods were covered during meal preparation and failed to allow two pans to air dry before using them also to prevent debris from contaminating the foods. [NAME] D also dried two pans with paper towels then used them during meal prep which could also contaminate the food. These deficient practices could affect the majority of residents who ate from the kitchen and could result in resident getting sick due to the spread of food borne illnesses. Observation on 10/15/24 at 9:05 AM revealed a pan of wheat rolls sitting on the side tabletop of the steam table. The pan of wheat rolls was not covered. Observation and interview on 10/15/24 at 9:16 AM revealed a pan of wheat rolls sitting on the side tabletop of the steam table. The pan of wheat rolls was not covered. Interview with [NAME] C revealed she did not cover the rolls with wax paper because the wax paper would get stuck to the rolls. She stated she understood all food should be covered to prevent from debris landing on it and risk contaminating the food. [NAME] C stated it could make the residents sick. Observation and interview on 10/17/24 at 10:58 AM revealed covered pans of food on the steam table. There was a large pan full of chicken fried steak on the steam table as well. It was not covered. Interview with [NAME] D revealed she was getting ready to take temperatures of the food. She called out the following temperature for the macaroni and cheese was 100 degrees. [NAME] D stated she would put it back in the oven until it reached temperature of at least 135 degrees. She stated the steam table was set at 10 which was the highest setting. Observation on 10/17/25 at 11:05 AM revealed the pan of chicken fried steak was still uncovered. Further observation revealed a large pan of corn bread, sprinkled with honey, was on the prep table. It was not covered. Observation and interview on 10/17/24 at 11:07 AM revealed [NAME] D removed the puree macaroni and cheese from the oven. She stated the temperature was 120 degrees and placed it on the steam table. Observation interview on 10/17/24 at 11:12 AM revealed [NAME] D stated the pureed spinach was 131 degrees and the puree macaroni and cheese was 100 degrees. [NAME] D left the items on the steam table. Observation on 10/17/24 at 11:13 AM revealed the DM covered the pan of cornbread with foil paper. Observation on 10/17/24 at 11:15 AM revealed a deep pan of ground beef patties in water next to the robocoupe blender on a prep table alongside the stove. The pan was not covered. Observation on 10/17/24 at 11:16 AM revealed [NAME] D took the temperature for the puree spinach again and stated it was 131 degrees and she also took the temp of the puree macaroni and cheese and stated it was 113 degrees. [NAME] D grabbed a ladle and stirred the puree macaroni and cheese. Observation and interview on 10/17/24 at 11:17 PM revealed [NAME] D removing a small pan and a long pan from the dish rack. Water was dripping from the pans onto the floor. [NAME] D placed the pans by the Robocoupe blender. The pan of boiled meat patties was still uncovered. [NAME] D then started looking for alternate thermometer reaching into the bottom shelf hanging right over the pan of meat patties. There were crumbs on the bottom shelf where [NAME] D reached into. Interview with [NAME] D revealed she changed from manual thermometer to digital thermometer and stated the DM had a digital thermometer in her office. Further observation revealed [NAME] D adding water to the pans on the steam table. She stated she noticed there was not enough water in the pans and that was why the steam table was not heating the food properly. Observation on 10/17/24 at 11:45 AM revealed [NAME] D initiated plating the lunch meal of the day which included Country Fried Steak, Country gravy, macaroni and cheese, spinach, cornbread, margarine, red velvet cake, coffee or tea and garnish parsley sprig. Interview on 10/17/24 at 1:57 PM with [NAME] D revealed she had been a cook for 6 months. She stated she felt nervous and was having trouble with the temperatures and had to make adjustment. She stated she felt distracted. [NAME] D stated all food should reach at least 135 degrees for safe service. She stated the puree macaroni and cheese, and the puree spinach did not reach 135 degrees. [NAME] D stated she did not write the temperatures down as she took them and was unsure what the exact temperature was for all food items. She stated she served all items on the steam table even the ones that did not reach temperature. Further interview revealed [NAME] D stated she used the pans she took from the dish rack for the puree and mechanical soft meat patties. Initially, she stated the pans were dry and then stated she remembered they were wet because she wiped the inside of the pans dry with a paper towel. She stated the pans should be air dried to prevent bacteria from forming. [NAME] D stated all the pans of food on the steam table were covered with foil paper to keep at safe temperature. She stated she uncovered the pan of chicken fried steam to take the temperature of the meat but then she did not cover it back up. [NAME] D stated food on the steam table should also be covered to prevent from debris landing on the food. It could make the residents sick. [NAME] D stated the beef patties were also not covered. She stated again she felt nervous and distracted. [NAME] D stated she saw a fly in the kitchen but stated flies did not get into the kitchen very often. [NAME] D also stated she did not cover the pan of cornbread because she was going to cut it. Interview on 10/18/24 at 10:35 AM with the DM revealed food temperatures should reach 135 to 165 degrees for safe service. She stated she understood [NAME] D missed some things She stated she talked with [NAME] D who said she was nervous and was distracted because the food temperatures were not all reaching 135 degrees. The DM stated it was important food items reached at least 135 degrees and hold for serving to prevent the development of food borne illnesses to prevent residents from getting sick. She stated she did not know the food had to reach 165 degrees for at least 15 seconds after rewarming before serving. The DM revealed food Items should be covered related to cross contamination, debris falling in it and contaminating the foods, infection control and to prevent the spread of diseases. The DM also stated flies usually did not get into kitchen but the door was opened more than usual as a result of the food delivery. The DM stated pans should be air dried and staff should not use paper towels to dry because it could get resin (According to Wikipedia, Polyamide epichlorohydrin (PAAE) is a permanent wet strength additive used in papermaking) on the pan and contaminate the pan that had been sanitized. Review of facility policy, Food Preparation and Handling revised on June 1, 2019 read in relevant part: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and Us Food Codes and HACCP (according to Wikipedia it is Systems and methods for monitoring food processing and food storage) guidelines. Procedure: 1. General Guidelines a. Use clean, sanitized surfaces, equipment and utensils. 4. Hot Food Temperatures: f. fresh, frozen, or canned fruits and vegetables that are cooked for hot holding shall be cooked to a minimum temperature of 140-degree F. Review of FDA Food Code 2022 read in relevant part: 3-403.11 Reheating for Hot Holding. (A) Except as specified under (B) and (C) and in (E) of this section,TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC (165oF) for 15 seconds. 4-9 Protection of Clean Items 4-901 Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry.

Based on observation, interview and record review revealed the facility failed to dispose of garbage and refuse properly for 1 of 4 survey dates (10/18/24). The facility failed to ensure all dumpster's had a plug at the bottom to keep spillage and the attraction of insects, bugs and rodents which could carry diseases and infections. This deficient practice could affect all residents and result in the spillage of trash seepage, attraction of bugs, rodents and insects that could enter the facility. The findings were: Observation on 10/18/24 at 11:20 AM revealed one of three dumpster's did not have a plug on the opening located one of the sides and bottom of the dumpster. The dumpster's were located within 10 to 15 feet away from the nursing facility. Interview with the DM stated the first dumpster did not have a plug on the opening. She stated all dumpster's should have a plug to prevent spillage from inside the dumpster which could be an infection control problem. She stated staff could step on the spillage and carry the germs inside the facility or flies could land on the spillage and carry the germs inside the facility. She stated the smell of trash could also attract insects, bugs and rodents and they could access the facility and resident rooms. The DM stated germs, diseases and infections could make the residents sick. Review of facility policy, Garbage Receptacles, revised June 1, 2019 read in relevant part: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. It should be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle.

Based on interview and record review the facility failed to ensure the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it in response to the pharmacist report for 1 of 2 Residents (Resident #15) reviewed for antipsychotic use. Nursing staff failed to ensure the attending physician responded to the pharmacists' recommendations for Resident #15. This deficient practice could affect residents who receive recommendations for psychotropic medications and result in the unnecessary adverse side affects. The findings were: Review of Resident #15's face sheet, dated, 10/18/24, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia, unspecified severity, with psychotic disturbance, Bipolar disorder, unspecified, Major Depressive disorder, recurrent, mild, Anxiety disorder, unspecified. Review of Resident #15's quarterly MDS, dated [DATE], revealed her BIMS was 7 reflective of severe cognitive impairment, was diagnosed with anxiety, Bipolar disorder and Dementia, unspecified severity, with psychotic disturbance and was receiving antipsychotic and antianxiety medications. Review of Resident #15's Care Plan revised on 9/10/24 revealed she had behaviors related to DX: Bipolar, Schizoaffective Disorder, Dementia w/ Psychotic Disturbance, Anxiety & Depression. Interventions included Administer antianxiety, mood stabilizers & antipsychotic medications as ordered. Observe/document for side effects and effectiveness. F/U with [Psychiatrist name] (Psychiatry) as ordered or needed. Review of Resident #15's physician's consolidated orders, dated October 2024, revealed the following orders: LORazepam Oral Concentrate 2 MG/ML (Lorazepam), Give 0.25 ml by mouth every 6 hours as needed for AGITATION, start date 10/17/24 for ANXIETY, OR RESTLESSNESS for 14 Days; LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth two times a day for AGITATION; risperiDONE Oral Tablet 2 MG (Risperidone) Give 1 tablet by mouth in the morning for BIPOLAR; risperiDONE Oral Tablet 3 MG (Risperidone) Give 1 tablet by mouth at bedtime for BIPOLAR; and Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml by mouth every 12 hours for seizures. Review of Resident #15's MAR for October 2024 revealed Resident #15 was receiving Lorazepam, RisperiDONE and Valproic Acid according to physician's orders. Review of Resident #15's Consultant Pharmacist/Physician Communication reviews revealed on 9/25/23 the review read: Per CMS regulations please evaluate resident for trial dose reduction. Clonazepam 0.25mg po on time a day for anxiety since 3/21/23 Clonazepam 0.5mg po hs for anxiety since 12/4/22 Risperidone 3mg po hs for Bipolar Disorder since 3/30/23 Resident is also receiving: Depakene 250mg/5ml give 10ml=500mg po bid for Bipolar Disorder If dose reduction is contraindicated or resident failed previous dose reduction attempt, please document below. Further review revealed response, Psych managing with an illegible signature and dated, 10/4/23. There was no response to the recommendation. Review of Resident #15's Consultant Pharmacist/Physician Communication reviews revealed on 1/11/24 read Per CMS regulations please evaluate resident for trial dose. Depakene 250mg/5ml give 10ml=500mg po bid for Bipolar Disorder since 1/30/23 Resident is also receiving: Clonazepam 0.25mg po one time a day for anxiety Clonazepam 0.5mg po hs for anxiety Risperidone 3mg po hs for Bipolar Disorder If dose reduction is contraindicated or resident failed previous dose reduction attempt, please document below. Further review revealed response, under psychiatric care with an illegible signature and dated, 2/6/24. There was no response to the recommendation. Review of Resident #15's EHR revealed there was no documentation from the PCP regarding the pharmacist's recommendations dated 9/25/23 and 1/11/24. Interview on 10/18/24 at 12:48 PM with the DON revealed Resident #15 was receiving LORazepam Oral Concentrate 2 MG/ML PRN and scheduled LORazepam for anxiety, risperiDONE for BIPOLAR and Valproic Acid Oral Solution 250 MG/5ML as a mood stabilizer. The DON stated she received the pharmacist's recommendations for review. She stated the signature on the Consultant Pharmacist reviews revealed Resident #15's PCP signed them but did not respond to the actual recommendations which was required in order to make necessary changes to Resident #15's medication regimen. Review of facility policy, Consultant Pharmacist Services and Reports, revised 10/1/19, read in relevant part: The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapy are communicated to those with authority and or responsibility to implement the recommendations, and responded to in an appropriate and timely fashion. Procedure: 3. Recommendations are acted upon and documented by the facility staff and or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and or the consultant pharmacist may contact the Medical Director.

Based on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for 1 of 5 residents (Resident #4) reviewed for resident assessment. Resident #4 was not referred to the pre-admission screening and resident review (PASARR) program for a level II resident review despite having a serious mental disorder diagnosis. This failure could place residents at risk of not receiving specialized services to meet their needs. The findings were: Record review of Resident #4's face sheet dated 10/18/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), delusional disorders (classified as a psychotic disorder, a disorder where a person has trouble recognizing reality), alcohol dependence with alcohol-induced persisting dementia (form of dementia caused by long-term, excessive consumption of alcohol, resulting in neurological damage and impaired cognitive function), and generalized anxiety disorder (excessive, ongoing anxiety and worry that interferes with daily activities). Further review revealed major depressive disorder was the primary admitting diagnosis. Record review of Resident #4's annual MDS assessment dated [DATE] revealed the resident was not considered to have a serious mental disorder or illness by the state level II PASRR process, serious mental illness was left blank, and the resident had a BIMS score of 4 indicating the resident was severely cognitively impaired. The MDS reflected the resident had depression and a psychotic disorder. Record review of Resident #4's care plan undated revealed a focus initiated on 5/30/23 and revised on 8/28/24 for the resident being at risk of having behaviors related to her diagnoses Dementia w/agitation, irritability & psychosis; Major Depressive Disorder; Delusional Disorder; & Anxiety. She has voiced being tired and having trouble concentrating. HX of hiding medications & confusing them. HX of insomnia. Voices having little interest, feeling down and moving slower than normal. Interventions included giving the resident antidepressant and antipsychotic medications as ordered. Record review of Resident #4's PASRR (Preadmission Screening and Resident Review) level 1 screening form dated 5/23/22 revealed under the question if the resident had a mental illness was marked no. Record review of Resident #4's EHR revealed there was no evidence that a PASRR level 2 screening was completed for Resident #4. In an interview on 10/17/24 at 1:25 p.m. LVN A was unable to state why Resident #4's PASRR level 1 was marked no under mental illness and stated there was nothing she could see from the physician certifying dementia as the resident's primary diagnosis and would look for more information. In an interview on 10/18/24 at 11:18 a.m. LVN B stated Resident #4's PASRR level 1 should have been marked yes under mental illness and the resident should have been referred to the pre-admission screening and resident review (PASARR) program for a level 2 but they were contacting the physician because dementia was the primary diagnosis and they would likely have form 1012 completed. LVN B stated it was important for residents PASRR level 1 screenings to be correct so residents got a level 2 evaluation and PASARR specialized services if needed. LVN B stated LVN A was fairly new and was how it got missed but was being corrected . LVN B stated the facility was not aware of the error on Resident #4's PASRR level 1 screening form until brought to their attention by the surveyor. In an interview on 10/18/24 at 12:13 p.m. the facility PASARR policy was requested from the DON and she stated she would ask the regional consultant. In an interview on 10/18/24 at 12:17 p.m. the DON stated the facility did not have a PASARR policy.

47564 Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #3) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 1/26/2024. The noncompliance was identified as PNC. The IJ began on 1/26/2024 and ended on 1/26/2024. The facility had corrected the noncompliance before the survey began. 2. Nurse Aide-E transferred Resident #3 from the bed to the resident's wheelchair using a gait belt by herself and lower the resident to the floor on 02/04/2024. It caused skin abrasion to Resident #3's back. On 02/08/2024, CNA-F transferred Resident #3 into the resident's wheelchair utilizing a mechanical lift without another CNA, and it caused the resident slid out of his wheelchair and no injury noted. This deficient practice could place residents at-risk of harm, serious injury, or death. The findings included: 1. Record review of Resident #1's admission record, dated 09/26/2024, reflected that Resident #1 was a [AGE] year-old female initially admitted on [DATE], with diagnoses that included unspecified dementia (group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #1's quarterly MDS assessment, dated 11/17/2023, reflected that Resident #1 had a BIMS score of 14, indicating cognitively intact. Resident #1 was assessed for using a wheelchair and a walker in the 7 days prior to assessment and was assessed as, supervision or touching assistance for the ability to walk at least 50 feet and make 2 turns, and Not applicable for, the ability to walk at least 150 feet in a corridor or similar space. The MDS assessment further reflected that wandering behavior was not exhibited by Resident #1. Record review of Resident #1's care plan dated 9/26/2024, reflected 1/26/24 - Eloped from facility from 100 hall (therapy dept door) into parking lot. Continued to exit seek numerous times with interventions including, Behavior monitoring for exit seeking behaviors, Deer Oaks to provide psychological services, Memory Care Unit, with date initiated 1/27/2024. Record review of Resident #1's elopement assessment from 11/8/2023 reflected her not to have wandered previously and to have been oriented with a short attention span. Record review of Resident #1's nursing note, dated 1/26/2024, revealed, [6:45 PM] RES NOTED SITTING UP IN W/C AT FRONT EXIT PUSHING ON EXIT DOOR. [Visitor] WAS TALKING TO RESIDENT AND REPORTED TO I CHARGE NURSE THAT RES WAS OUTSIDE IN THE PARKING LOT NEXT TO HER CAR. RES CONT TO PUSH ON DOOR TRYING TO EXIT FACILITY STATING SHE WANTED TO GO HOME. DOOR ALARM WORKING PROPERLY AT THIS TIME. REDIRECTION AT THIS TIME INEFFECTIVE. ADMINISTRATOR IN FACILITY AND WAS IMMEDIATELY NOTIFIED. WHILE SHE WAS TALKING TO RESIDENT REDIRECTING HER TO NOT LEAVE NO VISIBLE INJURIES NOTES FROM EXITING FACILITY. NO C/O OF PAIN OR DISCOMFORT. RES KEPT CRYING SAY SHE WANTED TO GO HOME. UPON PHYSICAL ASSESSMENT NOTED SMALL AMOUNT OF BLOODY DRAINAGE FROM PINPOINT SIZE AREA TO LT UPPER CHEEK. RES UNAWARE OF SITE. WHEN ASKED IF SHE SCRATCHED HERSELF SHE REFUSED TO SAY. RES REFUSED TO HAVE VITALS TAKEN. I CHARGE NURSE CALLED [PHYSICIAN] ON CALL TO REPORT INCIDENT. [PHYSICIAN] ORDERED TO PLACE RESIDENT IN MEMORY CARE UNIT FOR PERSONAL SAFETY AND ALLOW PINPOINT AREA TO SCAB OVER NO TREATMENT NEEDED. SON NOTIFIED AND CAME TO FACILITY TO HELP WITH RESIDENT. RECEIEVED PERMISSION FROM SON TO PLACE IN MCU. SON ALSO HELPED PERSUADE RESIDENT TO LET US DO A FLU SWAB TEST THAT WAS ORDER ON PREVIOUS SHIFT. RES ALSO TOOK HER HS MEDS. Record review of Facility Provider Investigation Report, undated, reflected that on 1/26/2023 at around 6:40 PM, resident #1 exited the 100-hall door. Staff responded to the alarm but did not see anyone outside. A visitor stated Resident #1 exited the facility through the 100 hall door and they located Resident #1 by their car. The visitor aided Resident #1 back into the facility. Resident assessment reflected resident was returned unharmed. Observation of door used for exit by Resident #1 was approximately 20 feet from the front door of the facility. Interview on 9/24/2024 at 10:24 AM, the DON and Admin stated neither of them were employed at the facility at the time of the incident, both having begun their employment at the building in June of 2024. Interview on 9/24/2024 at 11:43 AM, Resident #1 stated she was just upset at the time and did not have a plan to go anywhere, just wanted to go outside. Resident #1 stated she has not done it again, does not want to leave, and likes it at the facility. Interview on 9/24/2024 at 11:45 AM, ADON I stated that Resident #1 was confused and upset at the time, but that Resident #1 stated she did not have a plan to go anywhere and just wanted to go outside. ADON I stated that Resident #1 had been offered to discharge with home health with her son, but she declined and stated she preferred to stay at the facility. ADON I stated that Resident #1 was allowed to sign herself out on pass at the time, though that was revoked with her son's permission when the change in cognitive condition was recognized. The Administrator was notified on 9/26/2024 at 11:45 AM, a past non-compliance IJ situation had been identified due to the above failure. The facility implemented the following interventions. Record review reflected that the facility enhanced Resident #1's care plan to include a risk for elopement, psychological services, including family in care when resident is feeling emotional to help calm them, and moving the resident to the memory care unit for more specialized care. Record review of the facility's in-service records dated 1/27/2024 revealed all staff members across all departments and work shifts had signed and documented they received the trainings on elopement protocol and the new changes made after Resident #1's elopement. All new hires were also in-serviced as part of the new hire on-boarding process. Record review reflected that after the incident, regular elopement drills were in place once a month since January 2024 for 6 months and were being done at the time of survey. Review also reflected the drills were completed quarterly on different shifts. Interview on 9/25/2024 at 4:25 PM, CNA J stated she received elopement training when she began at the facility in the beginning of August and was able to explain the procedure to enact if a door alarm went off. Interview on 9/25/2024 at 4:31 PM, NA K stated she began the job recently and got extensive elopement training. She stated she knew and felt confident on what she would do if a door alarm went off and was able to easily re-direct residents if they attempt to elope, even if it is just going through the door to the main facility area from the memory care. Interview on 9/26/2024 at 4:53 PM, RN M stated she has worked here for about a year and has had elopement training multiple times, including in January 2024 after Resident #1 eloped. RN M was able to describe how to check the facility, indoor and outdoor, if there is a suspected elopement, and what to do if any fire door alarms are heard. Facility policy titled, Elopements and Wandering Residents, dated revised 11/21/22, reflected, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive the adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The Facility Elopements and Wandering Residents Policy then detailed the procedures for monitoring residents at risk for elopement, locating a missing resident, and procedure for post-elopement. 2. Record review of Resident #3's face sheet, dated 09/27/2024, reflected the resident was [AGE] years old, male, and originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of Alzheimer's disease (destroy memory and thinking skills), contracture to right ankle (shortening of muscles), type 2 diabetes mellitus (not control blood sugar levels), hemiplegia and hemiparesis (weakness or paralysis on one side), and muscle wasting and atrophy (thinning or loss of muscle tissue). Record review of Resident #3's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident required substantial/maximal assistance (helper does more than half the effort) to sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #3's care plan, dated 01/17/2024, reflected Resident #3 required Chair/bed-to-chair transfer: the resident is dependent on the assistance of 2 staff using a Mechanical Hoyer Lift to transfer to and from a bed to a chair (or wheelchair). Record review of Resident #3's incident report, dated 02/04/2024, reflected Nurse was called to [Resident #3]'s room and noted the resident sitting on his buttock on the floor leaning against his wheelchair. Assessed the resident noted an abrasion to his back measuring approximately 14 centimeters. [Nurse Aide-E] stated she asked if the resident wanted to be a Hoyer lift [mechanical lift], he stated no, she [Nurse Aide-E] attempted to transfer when the resident's leg gave out, and [Nurse Aide-E] lowered the resident to the floor. The resident had usual range of motions noted to all four extremities without any complaint of pain or deformities. Record review of the facility in-service training report, dated 02/04/2024, reflected the facility provided in-services to Nurse Aide-E and all CNAs (total 34 CNAs) regarding all residents must have two employees when transferring a resident with a mechanical lift, if resident is care planned as a mechanical lift transfer, we must follow plan of care, never ask resident how they want to be transferred - if resident is requesting other form of transfer and/or care - Report to charge nurse immediately. Record review of the Nurse Aide-E's employee profile reflected the facility suspended the Nurse Aide-E on 02/04/2024 and terminated the employment on 05/02/2024. Record review of Resident #3's incident report, dated 02/08/2024, reflected [CNA-F] reported that [Resident #3] slid out of wheelchair onto floor landing on buttocks. The resident sitting on floor. Assessment done for injuries and reddish-purple discoloration present to outer aspect of left elbow. Skin intact. No swelling present. Record review of facility investigation report dated 02/08/2024, reflected [CNA-F] stated she [CNA-F] utilized the Hoyer lift [mechanical lift] to transfer [Resident #3] from his bed to his wheelchair without another staff. The resident began to slide once he was in the wheelchair, and [CNA-F] assisted the resident to the floor. Record review of the facility in-service training report dated 02/08/2024, reflected the facility provided in-services to CNA-F and all CNAs (total 40 CNAs) regarding Residents are to be transferred according to what in Kiosk. Hoyer lift transfers always require 2 training people. If a resident has declined and you feel the way of transferring need to change, let DON, ADON or case management know so it can be looked into and addressing. Record review of the CNA-F's employee profile reflected the facility suspended the CNA-F and terminated the employment on 02/08/2024. Observation on 09/25/2024 at 1:05 PM revealed CNA-G and CNA-H transferred Resident #3 from the wheelchair to the bed with a mechanical lift as the care plan (two persons with mechanical lift) without any issue. Interview on 09/25/2024 at 8:42 AM with Resident #3 stated two staff transferred the resident with a lift machine from the wheelchair to the bed or from the bed to the wheelchair all the time. Interview on 09/25/2024 at 10:24 AM with ADON-I stated the DON and Administrator working in February 2024 quit their job after 02/04/2024 incident and 02/08/2024 incident. Current DON and Administrator did not know regarding these incidents. However, ADON-I could remember these incidents because she worked on 02/04/2024 and 02/08/2024. The ADON-I acknowledged on 02/04/2024, Nurse Aide-E transferred Resident #3 without a mechanical lift, and on 02/08/2024, CNA-F transferred the resident with a mechanical lift by herself. Resident #3 required a mechanical lift with two staff all the time for transfer. The facility terminated Nurse Aide-E and CNA-F, and no incidents reported since 02/08/2024 when the facility completed providing in-services to all CNA (Certified Nurse Aide)s. Interview on 09/25/2024 from 09:29 AM to 4:37 PM with 11 CNAs who stated Resident #3 had a mechanical lift with two persons all the time for transfer, and they should look at Kardex of care plan to find out what kinds of transfer facility residents needed. If resident refused, they should notify it to charge nurses immediately. Interview on 09/27/2024 at 9:37 AM with DON who stated the DON did not know regarding Resident #3's 02/04/2024 incident and 02/08/2024 incident because she was hired on 06/19/2024. However, if the care plan said Resident #3 needed to have a mechanical lift with 2 staff for transfer, Nurse Aide-E and CNA-F should have transferred Resident #3 utilizing a mechanical lift with 2 staff. All nursing staff should follow the plans of care, and the potential harm was it might cause Resident #3's fall and result in serious injury, such as fracture. Record review on the facility policy and procedure, titled Mechanical Lift, date implemented 08/11/2022, reflected The portable lift required 2 people assist, that have completed competency training on the lift.

Based on interviews and record reviews, the facility failed to ensure residents received food provided and prepared in a from designated to meet individual needs for 1 of 3 residents (Resident #2). The facility failed to ensure Resident #2 received the correct diet texture to prevent a choking hazard when Resident #2 was served a regular texture diet despite being prescribed a pureed texture diet. This failure to follow dietary orders could place residents at risk of harm, serious injury, or death. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. The findings included: Record review of Resident #2's face sheet revealed an admitted [DATE] with an original admitted [DATE] with the diagnoses: Alzheimer's with late onset; heart failure; vascular dementia with psychotic disturbance; and dysphagia. Resident #2's Quarterly MDS dated [DATE] revealed max assist with ADLs,a mechanically altered diet, and had to be fed by staff. Resident #2 had a BIMS score of 1. Resident #2's Care Plan dated [DATE] revealed swallowing difficulties related to impaired cognition with interventions included, Provide, serve diet as ordered. With a date initiated of [DATE], and intervention, Diet as ordered with date initiated of [DATE]. of pureed texture food with honey thickened liquids consistency and must be fed. Record review of diet order dated [DATE] revealed Resident #2 was prescribed a pureed diet texture with a honey thick texture. Record review of Resident #2's progress note, dated [DATE] at 10:39 AM, revealed Resident slept through breakfast. When he woke up hungry and the aide gave him a Pimiento Cheese sandwich. Resident choked on sandwich and this nurse was able to do the Heimlich on the resident and he spit the food out without any complications. Resident has no C/O pain or distress. [Physician] is aware of the incident and the RP has been notified. Record review of Resident #2's hospital clinical record revealed an admitted to the regional hospital on [DATE] with a history of present illness that read, Chest x-ray showing right lower lobe pneumonia. Patient does have fairly advanced dementia has had some ongoing issues with swallow dysfunction associated with progressive cognitive decline. There was also concern that this may be attributed to aspiration, but no clear episode noted .Patient meeting sepsis criteria but no evidence of acute organ dysfunction. Further hospital record review reflect Resident #2 reportedly had a fever of 102 earlier in the day of [DATE] and an O2 saturation of ,d+[DATE] without supplemental oxygen. Record review of nurses' notes revealed Resident # 2 expired [DATE]. Resident # 2 was admitted on hospice for services on [DATE] with terminal diagnosis of Alzheimer's dementia. Record review revealed he had a life expectancy of 6 months with decline with feeding and swallowing difficulties which resulted in recurrent lower lobe pneumonia secondary to aspirations. The facility implemented the following interventions: Record review of in-services done on [DATE] for Abuse & Neglect and Dietary Textures were done for ,d+[DATE] employees received the in-service for dietary texture and following dietary orders, and not follow what residents' family does. During an interview on [DATE] at 9:05AM the DON stated a pimento cheese sandwich was not appropriate for a pureed diet. The DON stated the bread was difficult and could present as a choking hazard and the pieces in the pimento cheese could also cause choking. During an interview on [DATE] at 9:35AM, CNA C stated Resident #2 was hungry and she asked LVN B what she could give him and she told her a peanut butter and jelly or pimento cheese sandwich. CNA C stated Resident #2 was doing fine for a while and then he started choking. CNA C stated either her or LVN B tried to take away the sandwich and Resident #2 began to shove the food in his mouth. CNA C stated LVN B had to do the Heimlich maneuver once and dislodged the food. CNA C stated she was aware of his pureed diet but thought it was fine to give him the sandwich. CNA C stated his family would give him cookies and other things that were not a part of his diet. CNA C stated they had in-service on that if a family provides food that does not follow diet orders, it does not mean the staff should do the same. CNA C stated she now understands the reason why she should not give a resident the incorrect diet texture. CNA C stated she understood pimento cheese and bread is not safe because it was not pureed and that not adhering to the diet could lead to choking. CNA C stated she had not seen anyone else give the wrong diet and they multiple in-services on diet textures. Interview on [DATE] at 9:48 AM, LVN B stated that she knew Resident #2 was on a pureed diet and his family gave him solid food and thin liquid. LVN B stated that Resident #2 kept stating he was hungry, so she thought that because the family gave Resident #2 solid foods, he would be able to eat a pimento cheese sandwich. LVN B told CNA C to provide Resident #2 a pimento cheese sandwich cut into quarters and to only give him one quarter at a time. LVN B stated she heard Resident #2 coughing and went over and stood next to him. This was when LVN B asked CNA C if she cut up the sandwich and CNA C informed LVN B that she forgot. When Resident #2 stopped coughing, LVN B performed the Heimlich maneuver and dislodged the piece of food from Resident #2's throat. LVN B stated that she believed pimento cheese could be pureed, but was not sure, and that she thought it was safe for him to eat the sandwich slowly and with supervision. During an interview on [DATE] at 10:29AM, the Dietician stated that a pimento cheese sandwich was not appropriate to give a resident on a pureed diet because they cannot form a bolus and they were not able to swallow safely. The bread was not pureed and the pimento cheese was not pureed which does not make it safe for a pureed diet. During an interview on [DATE] at 11:10AM, the DM stated the pimento cheese was pre-made and delivered with other food items. DM stated she was told about the incident with Resident #2. The DM was told that Resident #2 was given a sandwich on the unit and he choked and the nurse was able to remove it. DM stated she asked who gave him the sandwich and was told that it was not dietary that gave him the sandwich. DM stated she, nor her staff, would give a resident on a pureed diet the pimento cheese sandwich because it was not the correct consistency for a pureed diet. DM stated it had to be more of a baby food consistency to facilitate swallowing and to prevent choking. The DM stated staff was in-serviced for correct diet consistencies. On [DATE] at 11:30AM the investigator received and observed a pimento cheese sandwich from Dietary Services with one slice of bread on [DATE] at 11:30AM. The pimento cheese had shredded cheese pieces as well as pimento peppers, all of regular consistency. This was the same cheese used by Dietary Services on the day the sandwich was given to Resident #2. During an interview on [DATE] at 1:13PM the ST stated Resident #2 had issues with swallowing and he would eat very fast. The ST stated for a while Resident #2 had a mechanical soft diet but because of his swallowing difficulties, he was put on a pureed diet. The ST stated sometimes he would allow help to eat which could facilitate a slower speed eating and sometimes he would refuse. He would be given verbal cues, but he would not listen to them which was another catalyst for his diet change to pureed. She stated pimento sandwich was not safe for a resident on pureed diet unless it was pureed. During an interview on [DATE] at 4:36PM DA N (Dietary Aide) stated she had in-service for dietary consistency. DA N stated a pimento cheese sandwich would not be appropriate for someone on a pureed diet because they would not be able to chew the bread and the pimento cheese had pieces of food that would make it hard to swallow, especially the bread. During an interview on [DATE] at 4:43PM LVN L stated she was in-serviced on the different dietary textures and to follow the dietary orders and not what family does. LVN L stated a pimento cheese sandwich would not be safe because a resident on a pureed diet would not be able to swallow the bread and the cheese. LVN L stated pureed had the consistency of baby food and a sandwich was not that consistency. During an interview on [DATE] at 9:32AM RN O stated she was in-serviced about dietary textures and to follow physician's orders and not what family does. RN O stated nurses must check all the trays and snacks to ensure resident received the appropriate dietary per doctor's orders. Record review of in-services done on [DATE] for Abuse & Neglect and Dietary Textures were done for ,d+[DATE] employees received the in-service for dietary texture and following dietary orders, and not follow what residents' family does. Record review of Dietary Policy, undated revealed the facility will ensure food texture is appropriate to individual needs of the residents. The Administrator was notified on [DATE] at 11:45AM, a past non-compliance IJ situation starting on [DATE] and ending on [DATE] had been identified.

Based on interviews, and record review, the facility failed to ensure the right to be free from re misappropriation of funds was provided for 1 of 5 residents (Resident # 4), reviewed for misappropriation. The facility failed to ensure that Resident #4 was free from misappropriation of property when [NAME] D took $100 from the resident to buy Resident #4 a refrigerator and did not return. This failure could affect residents by putting them at a greater risk exploitation and diminished quality of life. The noncompliance was identified as PNC. The noncompliance began on 07/03/2024 and ended on 07/04/2024. The facility had corrected the noncompliance before the survey began. The Findings Included: Review of the facility's Face Sheet, Resident #4 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Genetic Torsion dystonia(A genetic disorder resulting in a defect in a protein called Torsin A affecting muscle control). Resident #4 has not discharged and was a current resident of this facility. During interview with Resident #4 on 10/26/24 at 1:14 p.m., Resident #4 stated she had given [NAME] D the sum of $100.00 when she offered to purchase a refrigerator for her. During interview with ADMIN on 9/24/24 at 1:00 p.m., ADMIN confirmed that [NAME] D had acknowledged she had taken the money, never returned to work and would not respond to further phone calls & messages to contact her. ADMIN confirmed that police were notified Case # 24-002402. ADMIN confirmed [NAME] D's employment was terminated on 07/04/24. Review of Petty Cash Log revealed that facility reimbursed Resident #4 $100.00 on 7/3/24. Interview with Resident #4 on 9/26/24 at 1:14 p.m. confirmed that she received $100.00 from facility. A review of the facility's Abuse, Neglect and Exploitation Policy implemented 8/15/22 reflected that was the policy of the facility to 1.a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; II.A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation; II. B. Existing staff will receive annual education through planed in-services and as needed; and IV. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Review of Employee file revealed [NAME] D held a current Texas Food Handlers Certification, completed orientation on 8/17/23 to include Maintaining resident rights including dignity, mail, visitors, personal property and telephone. Background Profile 8/11/23 reflected clear public records; Misconduct Registry 1/26/24 reflected no Results found; and Criminal History Conviction search reflected no search results found date?. Record review of facility investigation report dated 7/4/24, reflected the Administrator reported incident to appropriate state agency, suspended [NAME] D pending investigation, completed Abuse, Neglect & Exploitation in-service 7/3/24 with emphasis on misappropriation, completed resident interviews, notified police, validated Resident #4 allegation, and terminated [NAME] D on 07/04/2024.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder recieved appropriate treatment and services for 1 of 4 residents (Residents #3) reviewed for infection control, in that: CNA-G touched Resident #3's clean brief with dirty gloves after cleaning the resident's bowel movement while providing incontinent care to Resident #3 on 09/25/2024 at 1:12 PM. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #3's face sheet, dated 09/27/2024, reflected the resident was [AGE] years old, male, and originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of Alzheimer's disease (destroy memory and thinking skills), contracture to right ankle (shortening of muscles), type 2 diabetes mellitus (not control blood sugar levels), hemiplegia and hemiparesis (weakness or paralysis on one side), and muscle wasting and atrophy (thinning or loss of muscle tissue). Record review of Resident #3's quarterly MDS (Minimum Data Set ), dated 06/20/2024, reflected the resident's BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was dependent to toilet hygiene and shower/bathe self. Further record review of the MDS indicated Resident #3 was always incontinent to bladder and bowel. Record review of Resident #3's care plan, dated 12/14/2018, reflected [Resident #3] has total incontinent of bladder and bowel; intervention for decreased risk of septicemia to prevent urinary tract infection - clean peri-area with each incontinence episode. Observation on 09/25/2024 at 1:12 PM revealed while CNA-G and CNA-H were providing incontinent care to Resident #3, CNA-G and CNA-H rolled the resident to right, and CNA-G cleaned the resident's buttock because the resident had bowel movement. CNA-G finished cleaning the bowel movement, then touched Resident #3's clean brief with the dirty gloves and put the clean brief under the resident's buttock area, then closed the new brief. Interview on 09/25/2024 at 1:30 PM with CNA-G who stated she touched Resident #3's new brief with dirty gloves after cleaning the resident's bowel movement. The CNA-G should have changed the dirty gloves to new gloves after sanitizing her hands because CNA-G's gloves became dirty after cleaning the resident's bowel movement before touching the resident's new brief. CNA-G was nervous so forgot changing gloves. Interview on 09/27/2024 at 9:37 AM with DON who stated CNA-G should have changed the dirty gloves to new gloves after sanitizing her hands before touching Resident #3's new brief to prevent possible infection. Record review of the facility policy and procedure, titled Perineal Care, date implemented 10/24/2022, reflected . 9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then removed and discard - a. cleans buttock and anus, front to back and b. thoroughly dry. 10. Re-position resident in supine position. Change gloves if soiled and continue with perineal care 16. Remove gloves and discard. Perform hand hygiene and replace all equipment used.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals for 3 residents (#15, #41 and #127) out of 6 residents observed for oxygen therapy in that: 1. Resident #15's nasal cannula tubing was lying on her bed and not placed in the plastic bag provided at her bedside when not in use. 2. Resident #41's oxygen nebulizer mask was unbagged when not in use. 3. Resident #127's oxygen nebulizer mask was unbagged when not in use. These deficient practices could affect residents on oxygen and nebulization therapy and place them at risk for respiratory distress. The findings included: 1. Record review of Resident #15's electronic face sheet dated 09/14/2023 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses which included: dementia, a range of conditions that affect the brain's ability to think, remember and function normally) acute bronchitis (condition when the lining of the bronchial tube which carries air to and from the lungs is inflamed and can cause shortness of breath), hypoxemia (underlying illness that affects blood flow or breathing which leads to low oxygen levels in the blood) and Parkinson's disease (condition that affects the brain and causes problems with movement, balance and coordination). Record review of Resident #15's quarterly MDS assessment with an ARD of 08/31/2023 revealed she scored a 02/15 on her BIMS which indicated she was severely cognitively impaired. Further review reflected she was on oxygen therapy while a resident at the facility. Record review of Resident #15's comprehensive person-centered care plan with a revision date of 09/12/2023 reflected Focus .is at risk for ineffective breathing pattern related to .acute bronchitis .Interventions .oxygen as ordered. Record review of Resident #15's Active Orders As of: 09/14/2023 reflected Oxygen at 2 LPM via nasal cannula every shift for Hypoxemia **May be off for short periods', Active 12/05/2022. Record review of Resident #15's MAR dated 09/01/2023 to 09/30/2023 reflected she received oxygen at 2 LPM via nasal cannula every shift for her hypoxemia. Observation on 09/12/2023 at 10:30 a.m. of Resident #15's room revealed her oxygen nasal cannula tubing was lying on her bed and not placed in the plastic bag by her bedside stand. Observation on 09/14/2023 at 1:30 p.m. of Resident #15 revealed she was lying in bed with her oxygen nasal cannula on and her concentrator was set at 2 LPM. Interview on 09/15/2023 at 08:32 a.m. with CN A D revealed she was the C NA on the hall with Resident #15 on 09/12/2023 and may have set her oxygen nasal cannula tubing on her bed instead of placing it in the plastic bag beside her bed. She stated it was important to place the tubing into a plastic bag to keep any dirt or dust from getting into the tubing which would cause respiratory distress. Interview on 09/15/2023 at 2:00 p.m. with the DON revealed staff are trained to place oxygen tubing and breathing equipment when not in use into the plastic bags to prevent them from getting soiled or damaged which could cause respiratory compromise. Record review of facility policy and procedure titled Oral Inhalation Administration revised date 10/01/19 reflected Store oxygen tubing and mask in plastic bag when not in use. 2. Record review of Resident #41's electronic face sheet, dated 09/13/2023, revealed an initial admitted [DATE] and re-admitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), sepsis (blood poisoning), emphysema (lung condition that causes shortness of breath), and chronic respiratory failure with hypoxia (decreased level of oxygen in all or part of your body) and hypercapnia (CO2 retention, condition of abnormally elevated carbon dioxide levels in the blood). Record review of Resident #41's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Further review revealed the assessment indicated Resident #41 had received oxygen therapy during the 14-day look back period. Record review of Resident #41's care plan, last review date 09/05/2023, revealed a focus area [Resident #41] is at risk for ineffective breathing pattern related to DX: COPD, CHF, CKD 3b, Chronic Hypoxic & Hypercapnic Respiratory Failure, Cirrhosis, Pleural Effusion, Emphysema, Chronic Dyspnea, & Chronic Pulmonary Edema and a goal for optimal breathing patterns through review date initiated 02/27/2023, with a revision on 07/12/2023 and target date of 10/12/2023. Further review of Resident #41's care plan revealed an intervention Administer routine and PRN nebulizer treatments as ordered/needed. Following surveyor intervention, a record review of Resident #41's care plan revealed [Resident] has been noted removing his nebulizer mask and setting it at his bedside. He will take his oxygen off and throw tubing down, on the bed, bedside table & floor at times, with a revision date of 09/12/2023. Record review of Resident #41's active orders, dated 09/13/2023, revealed an order for Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)) 1 vial inhale orally two times day for COPD rinse mouth after use, with a start date of 07/14/2023 and DuoNeb Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 unit inhale orally every 6 hours as needed for COPD related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED with a start date of 07/10/2023. An observation and interview with Resident #41 on 09/12/2023 at 11:44 a.m., revealed Resident #41's nebulizer mask was hanging between the bed and bedside table unbagged. Resident #41 revealed nursing staff perform nebulizer treatments. He stated, I don't fool with it here like I did at home, they come in and do it when it's time. Resident #41 stated he was not aware of a bag for his nebulizer mask. 3. Record review of Resident #127's electronic face sheet, dated 09/13/2023, revealed an admitted [DATE] with diagnoses that included: aftercare following explantation of hip joint prosthesis, polyosteorarthritis (any type of arthritis that involves 5 or more joints simultaneously) and emphysema (lung condition that causes shortness of breath). Record review of Resident #127's Admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Further review of the assessment revealed Resident #127 had not received oxygen therapy within the 14-day look back period. Record review of Resident #127's care plan, last review date 08/14/2023, revealed a focus area [Resident] is at risk for ineffective breathing pattern related to DX: Emphysema, CHF, & Allergic Rhinitis with an intervention Administer nebulizer treatments as ordered. Record review of Resident #127's active orders, dated 09/13/2023, revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for CHF, with a start date of 08/23/2023. An observation and interview with Resident #127 on 09/12/2023 beginning at 1:00 p.m., revealed Resident #127's nebulizer mask resting on top of the bedside table behind his bed was unbagged. Resident #127 stated he had not taken a treatment in a long time and would refuse them because they make me cough so hard I can't breathe. In an observation and interview with the ADON on 09/12/2023 beginning at 1:10 p.m., the ADON stated Resident #41's nebulizer mask should have been bagged. The ADON revealed an uncovered mask could place the resident at risk of a respiratory infection. In an observation and interview with the ADON on 09/12/2023 beginning at 1:17 p.m., the ADON confirmed Resident #127's nebulizer mask should have been bagged. The ADON revealed she felt the resident removed the mask from the plastic bag at times. The ADON further stated that both nursing and CNA staff can ensure the resident's nebulizer masks remain in a plastic bag each time they are in the room. In an interview with the DON on 09/14/2023 at 3:53 p.m., the DON confirmed all respiratory masks should be placed in a plastic bag and dated when not in use to prevent respiratory infections. Record review of the facility's policy titled Medication Administration: Oral Inhalation Administration revised date 10/01/19 revealed Nebulizer - 23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 44903

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 residents (Resident #277) reviewed for baseline care plan, in that: The facility failed to ensure Resident #277's baseline care plan included information related to resident's use of oxygen therapy. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #277's face sheet, dated 09/15/2023, revealed an admitted [DATE] with diagnoses that included: secondary malignant neoplasm (cancerous tumor) of brain, malignant neoplasm (cancerous tumor) of upper lobe, pulmonary hypertension (increased blood pressure in the arteries of the lungs) and chronic obstructive pulmonary disease (progressive lung disease; long term respiratory symptoms and airflow limitation). Record review of Resident #277's Admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognition to be intact. Further review in Section O, Special Treatments, Procedures, and Programs, revealed Resident #277 had received Oxygen therapy and Non-Invasive Mechanical Ventilator (BiPaP/CPAP) both while not a resident at the facility and while a resident of the facility within the last 14 days. Record review of Resident #277's baseline care plan, effective date 09/01/2023, revealed no focus area for Resident #277's oxygen therapy needs. Record review of Resident #277's Order Summary Report, Active Orders as of 09/15.2023 revealed an order, Apply O2 at 5LPM via NC continuous. every shift related to MALIGNANT NEOPLASM OF UPPER LOBE, LEFT BRONCHUS OR LUNG, with a start date of 09/01/2023 and a second order, Place CPAP on at HS at bedtime, also with a start date of 09/01/2023. Further review of the active orders revealed an order, assess after administering Nebulizer Treatment two times a day with a start date of 09/05/2023. In an observation and interview with Resident #277 on 09/12/2023 at 1:35 p.m., Resident #277 was observed with O2 at 5 LPM. Resident #277 CPAP was observed lying on the bedside table. Resident #277 revealed the CPAP machine belonged to her, that she used it each night and had used the CPAP prior to moving into the facility. In an interview with LVN F on 09/15/2023 at 1:57 p.m., LVN F confirmed Resident #277's oxygen and CPAP requirements were not addressed in the baseline care plan. LVN F stated she had included Resident #277's respiratory issues in her initial nursing assessment however the baseline care plan did not have a respiratory section to complete. In an interview with the DON on 09/15/2023 at 2:37 p.m., the DON confirmed Resident #277's oxygen therapy to include oxygen and CPAP use should have been included on her baseline care plan. The DON stated not having oxygen therapy on the care plan could place residents at risk of not receiving continuity of care. Record review of the facility's policy titled, Baseline Care Plan, date implemented 10/22/2022, revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.

Based on interviews and record reviews, the facility failed to transmit within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including a subset of items upon a resident's discharge with for 1 of 3 residents (Resident #74) reviewed for the transmittal of assessments, in that: Resident #74's discharge MDS reflected he was discharged to an acute hospital when he was discharged to the community. This deficient practice affects residents who are discharged and result in misinformation of resident status and condition. The findings included: Record review of Resident #74's electronic face sheet dated 09/15/2023 revealed he was initially admitted to the facility on [DATE]. He had diagnoses which included: bipolar disorder (mental illness which causes extreme mood swings), diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) with foot ulcer (open wound or sore that will not heal) and osteomyelitis (an infection in the bone caused by bacteria or fungi. Usually affects the long bones of arms and legs and may be life threatening). Record review of Resident #74's discharge MDS assessment dated [DATE] reflected he was discharged to an acute hospital. Further review reflected he scored a 13/15 on his BIMS which indicated he was cognitively intact. Record review of Resident #74's comprehensive care plan with a revision date of 08/03/2023 reflected Focus .active DC planning started .Interventions .Follow-up as needed to see if there are changes to the discharge plan. Record review of Resident #74's progress note dated 08/18/2023 written by LVN A revealed Note Text: Resident dc' d to home. Left facility via personal vehicle accompanied by family member. Meds reviewed with resident and stated understanding. Appt made for follow up with PCP on 8/21/23 @ 0900 [9:00 a.m.]. Resident made aware. All personal belongings gathered by resident. MD aware of resident dc' d to home. Interview on 09/15/2023 at 11:12 a.m. with LVN A revealed she was the nurse who discharged Resident #74 and he did not go to an acute hospital. LVN A stated he went home. Interview on 09/15/2023 at 11:20 AM with the SSD revealed Resident #74 was discharged to the community with home health and that was his discharge plan since his admission. Interview on 09/15/2023 at 1:47 p.m. with LVN B (Care Management Specialist and MDS Nurse) revealed that she did not know why she coded Resident #74's discharge MDS wrong. She stated she knew he was discharged to the community and she sent CMS a corrected MDS already. She stated it was important to know what his disposition and status was for follow-up care at the time of his discharge. Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019 revealed The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status.

Based on interview and record reviews the facility failed to ensure residents were free of significant medication errors for 1 of 11 residents (Resident #1) reviewed for significant medication errors. The facility staff failed to continue Resident #1's anticoagulant (Anticoagulants are a group of medications that decrease your blood's ability to clot) medication when she returned from the hospital after being gone less than 24 hours. The Resident missed 9 days of her anticoagulant medication which required treatment in a hospital for bilateral embolism (A pulmonary embolism is a clot in the veins of one or both lungs.) The noncompliance was identified as PNC(past non compliance). The IJ (immediate Jeopardy) began on 12/1/2022 and ended on 12/09/2022. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of serious harm or death due to not receiving physician ordered medication. Findings include: Record review of Resident #1's face sheet, dated 4/5/23, revealed an initial admitted [DATE] and re-admitted [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (Alzheimer's disease is a brain disorder that slowly erodes memory, thinking, and behavior), Acute Embolism and thrombosis of unspecified deep veins of left lower extremity (Acute embolism and thrombosis of unspecified deep veins of lower extremity. If the vein swells, the condition is called thrombophlebitis. A deep vein thrombosis can break loose and cause a serious problem in the lung), personal history of pulmonary embolism and paranoid schizophrenia (Schizophrenia is a mental disorder that affects how a person thinks, feels, and behaves.) Record review of Resident #1's Quarterly MDS assessment, dated 2/27/2023, revealed a BIMS score of 2, which indicated cognitively impaired cognition. Section N - medications indicated anticoagulant received. Record review of Resident #1's Care plan, with date initiated as 12/12/2022, and revision date of 3/1/2023, revealed a focus of: at risk for abnormal bleeding/bruising related to the use of anticoagulant medication. History: Bilateral popliteal vein thrombosis (A blood clot in your circulatory system) and bilateral pulmonary emboli's. Interventions: Administer anticoagulant medications as ordered by physician. Observe for side effects and effectiveness. This was initiated on 10/17/2022 and a revision on 11/15/2022 and 12/18/2022. Record review of Resident #1's physician orders, dated 10/18/2022, revealed medication Apixaban (blood thinner, anticoagulant) tablet 5.0 mg give 1 tablet by mouth two times a day. Record review of Resident #1's electronic medication administration record, for 12/1-12/31/2022, revealed medication Apixaban 5.0 mg give 1 tablet by mouth two times a day was not given beginning 12/1/2022 through 12/9/22, when Resident #1 went to the hospital. Record review of Resident #1's hospital medical records for 12/9/2022-12/12/2022, provided by facility revealed an admitting diagnosis of bilateral pulmonary embolism . Record review of Resident #1's nursing notes dated 12/9/2022 revealed Resident #1 had an elevated temperature of 103.3, oxygen saturation of 88%,and labored breathing. She was sent to the hospital on 12/9/2022. During an interview on 4/6/2023 at 9:16 a.m. with LVN B revealed he was not working in facility on the date of 12/9/2022, when Resident #1 needed to be sent to the hospital. He stated he had in services regarding admission orders and anticoagulant medications and their side effects. He further revealed he was aware of Resident #1 having physician prescribed anticoagulant medication and knew side effects such as bleeding could occur. He stated he also was aware that if an anticoagulant was not taken as ordered blood clots could occur or a pulmonary embolus may occur. During a telephone interview with LVN A on 4/6/2023 at 10:25 a.m., he stated he was the nurse on duty when Resident #1 came back from the hospital on 11/30/22. He stated orders were to resume previous medications. He stated there was no medication list provided. He further revealed Resident #1 had been discharged in the facility Electronic Medical Record system therefore he did not notice her past medications. He stated he was terminated from the facility because of what happened to Resident #1. He revealed no further information. During an interview on 4/5/2023 at 3:30 p.m., the facility DON revealed LVN A admitted Resident #1 on 11/30/22 back from an almost 24-hour emergency room visit for a chronic dislocated hip requiring treatment and then she was returned to the facility. She further revealed she was present on 12/9/22 when Resident #1 was sent to the hospital for a change in condition of feeling weak and not being like herself, which was alert, able to walk and to feed herself. DON further revealed on 12/10/2022 the spouse of Resident #1 came to facility and asked the DON if the resident had been getting her anticoagulant medication because she was diagnosed at the hospital with Bilateral Pulmonary Embolism. The DON started an investigation that day and then found the medication had not been given. The DON further revealed Resident #1's primary physician was notified on 12/9/2022 of Resident #1 not receiving her anticoagulant medication. During an interview on 4/6/2023 at 11:46 a.m., the facility DON revealed LVN A did not reach out for assistance or question the medical record for Resident #1. She further stated because the resident had been discharged before the full 24 hours, which was typically what the facility did, the error occurred. The DON stated the facility had all staff in services, and clip board in services (the DON goes around and individually speaks with staff.), 24 report summary, stand up and stand down meetings which the nurses came in and our IDT discussed the days occurrences. The DON revealed, she monitored staff through observations of practices while on duty, the ADON also did rounding checks. She stated the ADON'S did rounds and made sure medications were given to residents. They checked medication carts weekly for expired medications and to see if the medications the residents had ordered were correct. The DON stated they ensured residents were safe and free from harm through frequent ambassadors checking on residents and what the facility called a stop and watch which when an aide was alerted to something they filled out a form, gave it to the nurse of duty, and they would follow up with the care needed. The DON stated the potential consequences of Resident #1 not getting her anticoagulant as physician ordered was she could have had prolonged illness or died . When asked if the return of Resident #1 on 11/30/22 was discussed at the next morning meeting and reviewed for medications the DON stated, no because Resident #1 technically wasn't admitted to the hospital. She (Resident#1) went to the local ER and then went to another hospital ER, was not admitted and then came back to the facility . She (Resident #1) never should have been discharged at the facility because she wasn't gone a full 24 hours. The DON stated, the nurse(LVN A) just jumped the gun, and discharged her(Resident #1) in the system at the facility which made the medication list not available. During an interview on 4/6/2023 at 11:58 a.m., the facility Administrator stated she did not know why the deficient practice occurred and she was not the Administrator at that time. The Administrator stated she monitored staff by having morning and evening meetings where the nurses came in and told the department heads if there were any changes or concerns with residents each business day. This was attended by all department heads. The Administrator stated she did rounds throughout the facility and checked on residents and staff. During an interview on 4/6/2023 at 11:30 a.m. the DON and Regional Nurse Consultant reported medication order reviews and MAR to cart audits were completed 12/10/2022- 12/14/2022. Staff were educated on abuse and neglect. All nurses were educated on medication reconciliation, order entry, notification of physician for clarifying medication, discharge process and when and what type of discharge was needed when a resident left the facility, education on drug regimen review and notifying MD of any issues. All orders for admissions were verified by two nurses for accuracy 12/10/2022-12/14/2022. The DON and 1 designee reviewed resident orders on admission, readmission, and transfers during the morning clinical meeting to ensure orders were transcribed correctly and results of findings discussed in the monthly QAPI meeting. The DON stated LVN A was terminated on 12/13/22 due to Resident #1 incident. During an interview on 4/6/2023 at 11:30 a.m. the Administrator, DON, and Regional Nurse Consultant stated all staff had been educated, and monitoring continues. The DON reported there were no further issues with the residents receiving their anticoagulants. Record review risk management documents, 24 hr report daily revealed the facility had a Medical Director meeting each month. Record review of the facility's investigation, with a start date of 12/10/22, confirmed Resident #1 had not received her ordered anticoagulant medication from 11/29/22 until discharged to hospital on 12/9/22. The investigation determined the charge nurse LVN A had not transcribed the physician orders when she returned from theER on [DATE]. Record review of a statement, dated 12/10/22 by LVN A, revealed when resident came back from the hospital, they said to resume previous medications. No medication list was provided. I went through her discontinue meds and restarted the meds she had been on. Record review of intakes revealed the facility made a report to the State Survey Agency regarding the incident on 12/10/22. Record review of actions taken by the facility revealed on 12/10/22 a QAPI meeting was held with the former Administrator, Medical Director, DON, and Regional Nurse Consultant and a performance improvement plan was developed with immediate interventions, re-education, systemic changes, and monitoring outcomes. Record review of actions taken by the facility revealed on 12/10/22 and 12/11/22 all residents in the facility who received anticoagulants were reviewed for order accuracy, medication administration, and lab work if required and a binder was started. Record review of actions taken by the facility revealed on 12/10/22 all admissions, readmissions, and transferred residents for the last 30 days was started to ensure accuracy of orders and was completed by the DON, ADON, and Regional Nurse Consultant on 12/11/22. Record review of actions taken by the facility revealed on 12/10/22 a MAR to the medication cart review was started for all residents and completed by the DON, ADON, and Regional Nurse Consultant on 12/11/22. Record review of actions taken by the facility revealed on 12/10/22 an In-service training signed by the DON, ADON's, and Regional Nurse Consultant for review of all admissions within 24 business hours was to be completed for accuracy of physician orders, completion of required assessments and forms, verifying all medications were received from pharmacy, and care plans were in place with interventions and an admission/readmission checklist placed in charts. Record review of actions taken by the facility revealed on 12/10/22 and 12/11/22 all nurses were educated on the discharge and admission process with details the resident was not to be discharged from the facility until they had been out of the facility for 24 hours and upon admission, readmission, and return from the emergency room the admitting nurse would verify all medication with the physician and if the medication list was not sent with the discharge paperwork received by the facility, then the most recent medication list would be sent to the provider for review and confirmation. If the drug regimen review identified any issues the physician must be notified. The transfer/discharge form, and drug regimen review were also reviewed separately with the nurses on 12/11/22. Record review of actions taken by the facility revealed on 12/10/22 the DON, ADON's, and RN supervisor were educated that orders were to be reviewed daily for all new orders from admission, readmission, procedures, and ER visits with details on how to pull the order listing from the computer and looking for written orders at the nurses' station to verify and scan. Record review of actions taken by the facility revealed on 12/10/22 and 12/11/22 CMA's, LVN's, and RN's were educated on medication order management for understanding the process of entering medication orders into PCC (Point Click Care-Computer system) and how to review, clarify new and existing medication orders with physician medication reconciliation and sending the list for the physician to review. Record review of actions taken by the facility revealed on 12/10/22, 12/11/22, 12/12/22, 12/14/22, and completed on 12/16/22 all facility staff (housekeeping, dietary, therapy, nursing, CMA, and CNA's) were educated on abuse and neglect, how to report, and where the number was posted for reporting. Record review of the facility's, undated, Abuse Prevention, Identification and Reporting policy, revealed: Neglect is a pattern of conduct or inaction of a care provider that fails to provide goods or services that maintain physical or mental health or that fails to avoid or prevent physical or mental harm or pain, or an act of omission that constitutes a clear and present danger to health, welfare or safety of a resident. Record review of the facility medication reconciliation policy, date implemented 10/24/22, revealed . refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medication to the resident at all points throughout his or her stay. 4. Admission Processes: b. compare orders to hospital records, etc. Obtain clarification orders as needed. C. Transcribe orders in accordance with procedures for admission orders. d. Have a second nurse review transcribed orders for accuracy and cosign the orders, indicating the review This was determined to be Past Noncompliance Immediate Jeopardy (PCN IJ) on 4/6/2023 at 4:30 p.m. The Administrator was notified The Administrator was provided with the IJ template 04/06/2023 at 4:30 p.m. The facility had corrected the noncompliance before the survey began.

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that: Facility staff failed to provide Resident #1 with a complete admission head to toe skin assessment and failed to notify the MD six days after the admission that the resident's left great toe had a change of condition. Eight days after admission, the resident's left great toe was amputated on an emergency basis, at a local hospital, because of an infection to the left great toe This failure resulted in the identification of an IJ (Immediate Jeopardy) on 06/29/22. While the immediacy was removed on 07/01/22, the facility remained out of compliance at actual harm that is not immediate with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of their corrective actions . This failure could affect residents experiencing a skin infection and place them at risk of not receiving necessary emergency care and services and could result in health decline, and/or death. The findings were: Record review of Resident #1's face sheet, dated 06/29/22, and EMR (electronic medical record) revealed, the resident was admitted on [DATE] and discharged to hospital on 06/28/22 (for shortness of breath) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a Male; age 60. Advanced Directive was Full Code. RP (responsible party) was listed as: the resident. Record review of Resident #1's Care Plan revealed, no baseline care plan was completed. Record review of Resident #1's MDS (minimum data set), dated 06/28/22, revealed, o BIMS (brief interview of mental status) Score was not listed. o ADLs (activities of daily living): B/B (bowel and bladder) in progress (catheter for urine) Bowel not rated. Transfer extensive two staff. Bed Mobility extensive one or two staff. ROM (range of motion) not rated. Eating was set-up . Hygiene/Bathing-not rated. Record review of Resident #1's hospital photograph of the left toe dated 06/17/22 revealed the toe had no bone sticking out of the left great toe; previous hospitalization . [On 06/20/22 the local hospital transferred the resident to the nursing home]. Record review of Resident #1's ER report dated 06/28/22 read: History of Present Illness. Reason for Visit: [CONDITION(S)] [bone infection] Left Great Toe .When the dressing was removed, pt (patient) was found to have eschar (dead tissue) with ulceration and exposed bone. ( MD E) was consulted in the ER. Per his evaluation, pt (patient) had [CONDITION(S)] (infection) of the left great toe and needed amputation. [Reason nursing home sent Resident #1 to ER was for shortness of breath.]. Record review of Resident #1's MAR (medication administration record), dated June 2022 , revealed, no medications specific to wound care or an infection Record review of Resident #1's Skin Assessments revealed : Admissions (dated 06/20/22)-skin intact with skin tear on the right elbow and left foot (not documented ).[Only skin assessment because the resident was in the facility less than 8 days] Record review of Resident #1's Norton Scale, dated 06/20/22 revealed, a rating of 13 (high risk for pressure ulcers) Record review of Resident #1's MD A's note, dated 6/20/22 (H and P done in the facility), revealed, the resident developed wound to right elbow and left foot at home. The physician ordered, Dressing R (right) elbow, L (left) foot both pending wound care nurse (evaluation). MD A's note was reviewed by LVN B on 6/20/22 at 5:00 PM. [Evidence was derived from the physician's admission assessment]. Record review of Resident #1's physician's orders (written by MD A) did not reveal any orders for wound care to left great toe. Record review of Resident #1's TAR dated June 2022 revealed no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's Nurse Note dated 06/26/22 at 2:30 PM, authored by LVN B, read, Res (Resident #1) had a little blood on his pillow by his feet. Upon examination great toe to the left foot had skin peeled down mild swelling but has no signs or symptoms of infection. Toe is warm to touch no pus, foul odor, no redness nor streaking no drainage noted. Spoke with wound care nurse (LVN C) and she stated she need an order to perform wound care. Passed on in report res (Resident) will need an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Will continue to monitor . [Physician was not notified. Difficult to determine whether it was a change of condition given that at admissions LVN B did not assess the resident's feet or toes]. Record review of Resident #1's Nurse Note dated 06/27/22 at 3:30 PM, authored by LVN D, . ER. Informed me that patient (Resident #1) was cardiac cleared. But that patient would remain in hospital for ortho surgery regarding toe for left foot . Record review of facility's discharge list for the month of June 2022 revealed, Resident # 1 was discharged to hospital on 06/28/22 for respiratory distress [not an infection to the left great toe]. Observation and interview on 06/28/22 at 3:17 PM, Resident #1 was in a hospital bed; alert and oriented. Observation revealed the resident's left foot was bandaged with blood stains on the bandage, And an IV present in the hospital room connected to the resident. The resident had mobility difficulties in both arms. The resident stated, I fell at home in April 2022 and was sent to the hospital and discharged to the .Nursing home on June 20, 2022 . On June 27th I was sent to the ER because of shortness of breath .at the nursing home my left big toe was swollen bad and I received no treatments or wound care .my left big toe has been amputated . I would tell them [nursing staff-names not given] that my toe hurt and no wound care was given .the big left toe was not bad at first but I bumped it .it got worse [resident could not remember whether the toe was bumped at home or at the facility] [No incident report present of any alleged bump to the toe in the facility] .I told the nurses to check my toe and nothing was done .I do not remember who did my assessments at admission [LVN B] or whether a skin assessment was done .they were not checking my left big toe and it got bad the past two days .and now my left big toe is amputated .I was neglected .someone dropped the ball which led to my toe being amputated yesterday (06/27/22) .do not remember who at the nursing home wrapped my left big toe when I was sent to the hospital on June 27th .[no evidence surfaced that the left great toe was wrapped at the nursing home].[Evidence supports quality of care than neglect] During an interview on 06/28/22 at 3:30 PM, MD E (foot specialist) stated, the foot was infected at admission to the ER .the right big toe revealed the bone sticking out .it was a condition that required immediate surgery .I cannot say whether the patient (Resident #1) was neglected at the nursing home .but after the bandage was removed at the ER of the big left toe .we needed to proceed to immediate amputation because of the infection and the bone sticking out of the toe . [Physician did not provide information on how the bone sticked out except that the left great toe was infected with the exposure of the bone].[Physician did not want to express an opinion how the infection occurred]. During an interview on 06/29/22 at 8:11 AM, LVN C (former wound nurse-), stated, .In reference to Resident (#1) I never had wound care orders .I only saw him (Resident #1) on 06/26/22 to give him a phone message from family (to call) not to provide care or do a skin assessment .I stopped being wound nurse on 06/18/22 .after 06/18/22charge nurses were responsible for skin assessments [within a nurse scope of practice] and he was admitted on [DATE] .by nursing practice a skin assessment is done on admissions and the next day the treatment nurse checks the skin assessment . During an interview on 06/29/22 at 8:40 AM, LVN F (wound nurse) stated, I officially assumed the role of wound nurse on 06/27/22 and had no contact with Resident (#1) .by nursing practice a skin assessment is done at admissions and the treatment nurse checks the assessments and notifies the MD for any orders .any nurse can do a skin assessment [within the scope of a nurse]. During an interview on 06/29/22 at 8:49 AM, LVN B, stated, On June 20th (2022) I was the admitting nurse and admitted Resident (#1) I did the orders and notes .I did a skin assessment and his skin was intact but I did not take off his sock to check on the (left and right) feet .the acuity was high in the facility and I do not remember why I did not remove the resident's socks to check on the feet .yes, nursing practice is to do a head to toe skin assessment .he is a diabetic .I did not work from 06/21/22 to 06/24/22 and saw him (Resident #1) on 06/24/22 and his socks were still on and I did not check his feet; but on 06/26/22 I checked his left great toe and it was swollen [Physician was not notified. Facility policy was to notify the physician when there was a change of condition] [No incident report was completed and LVN B did not provide an explanation] .he had a skin tear under the toe .but no signs and symptoms of infection based on color, odor, warmth, and pain .the resident denied pain .I spoke to the treatment nurse (LVN C) and she said there was no treatment orders we did not notify the doctor because there were no signs of infection .I do not know whether the doctor was called on Monday (06/27/22) .my expectation was that the nurse (LVN C) would call the doctor on Monday .but I did not call the doctor .given the toe was only swollen . During an interview on 06/29/22 at 9:57 AM, LVN C (former wound nurse-), stated, on 06/26/22 LVN (B) told me that Resident (#1's) left great toe was swollen .I told her that I had no doctor's orders and she should call the doctor .I did not call the doctor because I expected her (LVN B) to call the doctor . During an interview on 06/29/22 at 10:15 AM, CNA G, stated, I worked with Resident (#1) on 06/25/22 and 06/26/22 I provided Foley care (empty the bag), assisted with feeding for two days and resident (consumed) his food, no bathing that day .I did see his (Resident #1) left big toe .it was swollen and a little red and there might have been some dried blood on the toe I told the treatment nurse (LVN C) after hours on the drive home with her around 5:40 PM and she told me to inform LVN B which I did the next day (06/26/22) around 9:00 AM . [CNA G could not recall LVN B's response]. During an interview on 06/29/22 at 2:35 , the MD A, stated, I saw the Resident (#1) on 6/20/22 and ordered a nurse wound assessment [found in the H&P as a written ordered] because the resident was in general pain and had a wrapping on his left foot and bandage to right elbow when he arrived .I was never called between 06/20/22 to 06/27/27. Later I found out by the covering physician that the resident's left great toe was amputated .the failure as I see it was not following doctor's orders and the nurses not communicating between each other . During interview on 06/29/22 at 5:13 PM, MD A stated, if the nurse (LVN B ) had called me, I would have directed for a full assessment of the left great toe to determine whether the bone was showing. If the bone was showing or there was an infection, given it was the weekend, I would have ordered the resident being sent to the hospital for a foot examination or an x-ray . During in interview on 06/29/22 at 5:55 PM, the Administrator was notified of the IJ and the IJ template was provided to the Administrator. During an interview on 07/01/22 at 1:44 PM, DON stated, involving quality of care the nurses did not respond appropriately .I do not understand why .the nurses failed to collaborate as to who was going to call the physician .they did not call me .they assumed .regarding the initial care plan not done .they might have been in a hurry and did not follow the normal process for an admission .they rushed but were trained on wound care and admission process and notifying the MD .the process for admission is to do a skin assessment [within 48 hours of admission] .and to notify the physician if there are issues .[Assessment was a complete head to toe skin assessment. Facility procedure was for a second nurse to check the assessments and develop a baseline care plan . During an interview on 07/01/22 at 2:10 PM, the Administrator stated, in reference to quality of care there was a breakdown of communications and the procedures we have were not followed .for instance, the admitting nurse should have done a full initial assessment which included skin assessment and any orders uploaded to PCC .either the admitting nurse forgot the process or was in a hurry or distracted .there was a breakdown in communications and I cannot explain why the MD was not called .the process was not done for the initial care plan .the process was not followed .regarding lack of competencies probably stems from not following the process for initial care plan and skin assessment and when to notify the MD . Record review of facility's Grievance Log for the month of June 2022 revealed, a family member filed a grievance involving Resident #1 on 06/28/22. The family member was concerned about Resident #1's elbow and (left) great toe issues and wanted an update. Record review of facility's Wound Care policy, revised 07/2015, read, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order for this procedure . [policy did not address when to complete skin assessments and to notify the physician of any change of condition] FACILITY PLAN OF REMOVAL - Received and approved 06/30/22 at 11:07 AM from the Facility Administrator. On 07/01/22 at 3:30 PM, the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal. Facility's POR: The [facility's name] Nursing and Rehabilitation Center June 29, 2022 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On June 29, 2022, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: F584 Quality of Care Facility failed to provide a resident treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices to prevent an infection to the left great toe which included: failure to do a full head to toe assessment, failure of nursing staff to observe the residents left foot as ordered by the physician six days after admission when a nurse aide notified nursing staff that the resident's left great toe, and failure to train nursing staff on completing full skin assessment on admissions and as required for 1 of 5 residents reviewed for prevention of pressure ulcers. Resident #1 no longer resides in the center. The Licensed Nurses performed 100% skin rounds on residents on June 29, 2022, to establish a baseline for residents' skin integrity. The MD and responsible party were notified if not previously completed. Treatment orders were reviewed and obtained if not in place. The care plan was reviewed and updated if not present for each resident with identified skin alteration. The Director of Nursing or designee-initiated re-education for Licensed Nurses began on 6/29/22 regarding the following policies: o Pressure Injury Prevention that includes completion of assessment upon admission, having and following orders for skin alteration o Notification of changes o Abuse and neglect Re-education will continue until 100% of staff have completed the education. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Re-education will be completed by 6/30/2022. New admissions will be reviewed in the morning clinical meeting, attended by the Interdisciplinary Team, to ensure that an assessment was completed on admission, if skin alterations are present, that there is an order and care plan in place. The Director of Nursing or designee will review the 24- hour report in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. The Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the admissions and the 24-hour report in the morning clinical meeting. An AdHoc QAPI was conducted on June 29, 2022, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning pressure ulcers and to develop the above-mentioned plan of care. Administrator [NAME] Nursing and Rehabilitation Monitoring and confirmation interviews: Item: ---Resident #1 is no longer in the Center: Record review of facility's discharge list for the month of June 2022 revealed, Resident #1 was sent to a local hospital on 06/28/22 at 3:17 PM. Observation on 06/28/22 of Resident #1 revealed he was in a hospital bed at a local hospital ---In-service on Pressure Injury Prevention, Notification of Changes, and Abuse & Neglect; 1.During an interview on 06/30/22 at 11:51 AM, LVN C (Day shift) stated, make sure of re-positioning and do timely skin assessments .notify MD immediately and documents changes in condition .on neglect to provide the services a resident's needs . 2.During an interview on 06/30/22 at 11:54 AM, Social Worker (day shift) stated, if we have concern or unusual report immediately to the nurse .immediately notify the nurse and the nurse should do an assessment and notify MD .types of abuse was explained . 3.During an interview on 06/30/22 at noon, CNA H (night shift) stated, repositioned resident every 2 hours and check skin for wounds and redness .notify nurse immediately concerns with skin issues .need to report and abuse and neglect immediately to the Administrator . 4.During an interview on 06/30/22 at 12:02 PM, CNA I(day shift) stated, .proper placement of resident to prevent wounds and pressure .report when you see a difference in the skin immediately to the nurse .report abuse and neglect immediately to the Administrator . 5.During an interview on 06/30/22 at 12:06 PM, LVN J ( day shift) stated, look for changes of the skin .if required report to the MD to prevent further injury .report suspicions of abuse or neglect to the Administrator immediately . 6. During an interview on 07/01/22 at 11:50 AM, LVN F (day shift) stated, major highlights were to do good assessments, notify MD with any change of condition, and report any allegations of abuse and neglect . 7. During an interview on 07/01/22 at 11:59 A, Housekeeping K (day shift) stated, in the training I was told to report any falls to the nursing staff and any abuse .if you see skin tears report to nursing .and report any abuse to the Administrator. 8. During an interview on 07/01/22 at12:05 PM, CNA L (day shift) stated, the main highlight of the training was to report abuse/neglect and any changes in skin and skin tears and wounds to nursing . 9. During an interview on 07/01/22 at 12:08 AM, RN M (day shift) .follow the doctor's orders, follow the treatment plan, and report changes of condition to MD and family . 10. During an interview on 07/01/22 at 12:10 AM, LVN N, (day) I learned to do a thorough assessment on admissions, verify if an abnormality are found report to MD, follow treatment orders .and do thorough skin assessments. 11. During an interview on 07/01/22 at 12:54 PM, CMA O (night shift) , stated, highlights of training were that if I notice any wound issues notify nursing staff .any signs of abuse and neglect report to the Administrator withing 2 hours . 12. During an interview on 07/01/22 at 12:57 PM, , CNA G (night shift) stated, the highlights of the training on wound care were to report any skin changes to the nurse and fill an incident report and document in PCC .there are different types of abuse and neglect and report any suspicions to the Administrator immediately . 13. During an interview on 07/01/22 at 1:01 PM, LVN P (night shift) stated, I learned from the training that if the treatment is not working or there is a change of condition to call the MD and RP .do head to toe assessments at admissions and weekly .update the CP based on any changes in condition .the MD should be notified immediately after you are done with the skin assessment if there concerns about the skin .and do measurements and document .and report any abuse/neglect to the administrator. 14. During an interview on 07/01/22 at 1:07 PM, LVN Q, (day/night shift) stated, .the top three things I heard about wound care were to check wounds and check for infections, notify doctor and family when you see redness or signs of infection and follow doctor's orders .at admissions do a thorough skin assessment and document .always report abuse and neglect to the Administrator . 15. During an interview on 07/01/22 at 07/01/22 at 1:13 PM, CNA R (day/night shift) stated, .at the training I understood that when you see skin tears, infections or bruises report immediately to the nurse and document in PCC .on abuse and neglect that we should be able to recognize the signs and to report to the Administrator . Record review of facility's staff list dated 06/28/22 revealed 75 staff on payroll. Record review of facility's in-service sign in sheets on 07/01/22 revealed, the staffing number was 75 with 7 staff listed as PRN; minus the PRN staff, 100% of staff for both the day (6AM-6PM) and the night (6PM-6AM) shifts had attended a session of the in-service training. ---New Admissions During an interview on 06/30/22 at 12:20 PM, the DON stated, there have been no new admissions from 06/28/22 to 6/30/22; the last new admissions was on 06/27/22 (Resident #7) The resident self-discharged the next day. Per the POR, we will ensure a skin assessment is present and an initial care plan is completed. This will be monitored by the charge nurse and I will re-check the admissions packet for every new admission. ---24-hour report During an interview on 06/30/22 at 12:20 PM, the DON stated, we will discuss the 24 report at morning meeting which was done today (06/and discuss any changes and the need to contact the physician and RP or family member . Record review of 24 report revealed it was located in PCC under the heading Order Listing report. ---QAPI During an interview on 06/30/22 at 12:20 PM, the DON stated, the next QAPI meeting is scheduled for the third Thursday of the month ( 07/21/22) and a topic to be address is compliance with the POR. ---Administrator/Morning Meeting During an interview on 06/30/22 at 12:41 PM, the Administrator revealed he will attend morning clinical meetings staring July 1, 2022 except on weekends when no official morning meetings are held. During an interview on 07/01/22 at 10:40 AM, the Administrator revealed he attended the clinical morning meeting on 07/01/22 at 9 AM. The topics discussed, according to the Administrator included, labs, Medicare days and new orders. During an interview on 07/01/22 at 10:45 AM, the DON confirmed that the Administrator was present at the morning meeting. ---Skin Assessments and CP review Record review of sample residents with wounds ( Resident #2, #3, #4, $5, and #6,) revealed , CP addressed skin assessments that were done and CP reflected wound care interventions. ---System Process Record review of Nurse Note dated 6/29/22 at 6:38 PM (authored by LVN C ) revealed, wound assessment was done on 06/29/22 and Resident #2 wounds increased in area of the right foot/ankle and the physician was notified and new orders issued. The physician assessed the resident on 06/29/22. The RP was also notified. The physician's new order was paint with [MEDICATION(S)] and leave open to air. 22 [MD called on 6/29/22 because the resident had more areas of wounds; resident has vascular disease] Record review of Nurse Noted dated 6/29/22 at 8:29 PM authored by RN S, revealed new skin assessments and MD was notified and ordered was given. Record review of Resident #2's CP, dated 06/29/22, revealed the CP was updated to reflect the resident had an arterial/ischemic ulcers (related to vascular insufficiency); and interventions included to monitor/document wound. Record review of Residents' updated skin assessments (residents with wounds) revealed the dates of the updated skin assessments were: Resident #3-06/29/22 Resident #4-06/28/22 Resident #5-06/28/22 Resident #6-06/28/22 Review of facility's policy, Change in a Resident's Condition or Status (undated) read Our facility should promptly notify a resident, his or her attending physician and responsible party, of changes in the resident's medical/mental condition and or status). b. A significant change in the resident's physical, mental, or psychosocial status (i. e. a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). c. A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or D. A decision to transfer or discharge the resident from the facility. On 07/01/22 at 3:30 PM, the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal

Based on observation, interview and record review the facility failed to immediately inform the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for 1 of 6 Residents (Resident #1) whose records were reviewed. LVN B failed to contact MD when Resident #1 had a change of condition (infection) to the left great toe on 06/26/22 . LVN C failed to contact MD when Resident #1 had a change of condition (infection) to the left great toe on 06/26/22 . Eight days (06/28/22) after admission (06/20/22), the resident's left great toe was amputated on an emergency basis, at a local hospital, because of an infection to the left great toe This failure resulted in the identification of an IJ (Immediate Jeopardy) on 06/29/22. While the immediacy was removed on 07/01/22, the facility remained out of compliance at actual harm that is not immediate with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of their corrective actions . This deficient practice could result in the physician not having the opportunity to issue medical orders for residents. The findings were: Record review of Resident #1's face sheet, dated 06/29/22, and EMR (electronic medical record) revealed, the resident was admitted on [DATE] and discharged to hospital on 06/28/22 (for shortness of breath) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a Male; age 60. Advanced Directive was Full Code. RP (responsible party) was listed as: the resident. Record review of Resident #1's Care Plan revealed, no baseline care plan was completed. Record review of Resident #1's MDS (minimum data set), dated 06/28/22, revealed, o BIMS (brief interview of mental status) Score was not listed. o ADLs (activities of daily living): B/B (bowel and bladder) in progress (catheter for urine) Bowel not rated. Transfer extensive two staff. Bed Mobility extensive one or two staff. ROM (range of motion) not rated. Eating was set-up . Hygiene/Bathing-not rated. Record review of Resident #1's hospital photograph of the left toe dated 06/17/22 revealed the toe had no bone sticking out of the left great toe; previous hospitalization . [On 06/20/22 the local hospital transferred the resident to the nursing home]. Record review of Resident #1's ER report dated 06/28/22 read: History of Present Illness. Reason for Visit: [CONDITION(S)] [bone infection] Left Great Toe .When the dressing was removed, pt (patient) was found to have eschar (dead tissue) with ulceration and exposed bone. ( MD E) was consulted in the ER. Per his evaluation, pt (patient) had [CONDITION(S)] (infection) of the left great toe and needed amputation. [Reason nursing home sent Resident #1 to ER was for shortness of breath.]. Record review of Resident #1's MAR (medication administration record), dated June 2022 , revealed, no medications specific to wound care or an infection Record review of Resident #1's Skin Assessments revealed : Admissions (dated 06/20/22)-skin intact with skin tear on the right elbow and left foot (not documented ).[Only skin assessment because the resident was in the facility less than 8 days] Record review of Resident #1's Norton Scale, dated 06/20/22 revealed, a rating of 13 (high risk for pressure ulcers) Record review of Resident #1's MD A's note, dated 6/20/22 (H and P done in the facility), revealed, the resident developed wound to right elbow and left foot at home. The physician ordered, Dressing R (right) elbow, L (left) foot both pending wound care nurse (evaluation). MD A's note was reviewed by LVN B on 6/20/22 at 5:00 PM. [Evidence was derived from the physician's admission assessment]. Record review of Resident #1's physician's orders (written by MD A) did not reveal any orders for wound care to left great toe. Record review of Resident #1's TAR dated June 2022 revealed no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's Nurse Note dated 06/26/22 at 2:30 PM, authored by LVN B, read, Res (Resident #1) had a little blood on his pillow by his feet. Upon examination great toe to the left foot had skin peeled down mild swelling but has no signs or symptoms of infection. Toe is warm to touch no pus, foul odor, no redness nor streaking no drainage noted. Spoke with wound care nurse (LVN C) and she stated she need an order to perform wound care. Passed on in report res (Resident) will need an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Will continue to monitor . [Physician was not notified. Difficult to determine whether it was a change of condition given that at admissions LVN B did not assess the resident's feet or toes]. Record review of Resident #1's Nurse Note dated 06/27/22 at 3:30 PM, authored by LVN D, . ER. Informed me that patient (Resident #1) was cardiac cleared. But that patient would remain in hospital for ortho surgery regarding toe for left foot . Record review of facility's discharge list for the month of June 2022 revealed, Resident # 1 was discharged to hospital on 06/28/22 for respiratory distress [not an infection to the left great toe]. Observation and interview on 06/28/22 at 3:17 PM, Resident #1 was in a hospital bed; alert and oriented. Observation revealed the resident's left foot was bandaged with blood stains on the bandage, And an IV present in the hospital room connected to the resident. The resident had mobility difficulties in both arms. The resident stated, I fell at home in April 2022 and was sent to the hospital and discharged to the .Nursing home on June 20, 2022 . On June 27th I was sent to the ER because of shortness of breath .at the nursing home my left big toe was swollen bad and I received no treatments or wound care .my left big toe has been amputated . I would tell them [nursing staff-names not given] that my toe hurt and no wound care was given .the big left toe was not bad at first but I bumped it .it got worse [resident could not remember whether the toe was bumped at home or at the facility] [No incident report present of any alleged bump to the toe in the facility] .I told the nurses to check my toe and nothing was done .I do not remember who did my assessments at admission [LVN B] or whether a skin assessment was done .they were not checking my left big toe and it got bad the past two days .and now my left big toe is amputated .I was neglected .someone dropped the ball which led to my toe being amputated yesterday (06/27/22) .do not remember who at the nursing home wrapped my left big toe when I was sent to the hospital on June 27th .[no evidence surfaced that the left great toe was wrapped at the nursing home].[Evidence supports quality of care than neglect] During an interview on 06/28/22 at 3:30 PM, MD E (foot specialist) stated, the foot was infected at admission to the ER .the right big toe revealed the bone sticking out .it was a condition that required immediate surgery .I cannot say whether the patient (Resident #1) was neglected at the nursing home .but after the bandage was removed at the ER of the big left toe .we needed to proceed to immediate amputation because of the infection and the bone sticking out of the toe . [Physician did not provide information on how the bone sticked out except that the left great toe was infected with the exposure of the bone].[Physician did not want to express an opinion how the infection occurred]. During an interview on 06/29/22 at 8:11 AM, LVN C (former wound nurse-), stated, .In reference to Resident (#1) I never had wound care orders .I only saw him (Resident #1) on 06/26/22 to give him a phone message from family (to call) not to provide care or do a skin assessment .I stopped being wound nurse on 06/18/22 .after 06/18/22charge nurses were responsible for skin assessments [within a nurse scope of practice] and he was admitted on [DATE] .by nursing practice a skin assessment is done on admissions and the next day the treatment nurse checks the skin assessment . During an interview on 06/29/22 at 8:40 AM, LVN F (wound nurse) stated, I officially assumed the role of wound nurse on 06/27/22 and had no contact with Resident (#1) .by nursing practice a skin assessment is done at admissions and the treatment nurse checks the assessments and notifies the MD for any orders .any nurse can do a skin assessment [within the scope of a nurse]. During an interview on 06/29/22 at 8:49 AM, LVN B, stated, On June 20th (2022) I was the admitting nurse and admitted Resident (#1) I did the orders and notes .I did a skin assessment and his skin was intact but I did not take off his sock to check on the (left and right) feet .the acuity was high in the facility and I do not remember why I did not remove the resident's socks to check on the feet .yes, nursing practice is to do a head to toe skin assessment .he is a diabetic .I did not work from 06/21/22 to 06/24/22 and saw him (Resident #1) on 06/24/22 and his socks were still on and I did not check his feet; but on 06/26/22 I checked his left great toe and it was swollen [Physician was not notified. Facility policy was to notify the physician when there was a change of condition] [No incident report was completed and LVN B did not provide an explanation] .he had a skin tear under the toe .but no signs and symptoms of infection based on color, odor, warmth, and pain .the resident denied pain .I spoke to the treatment nurse (LVN C) and she said there was no treatment orders we did not notify the doctor because there were no signs of infection .I do not know whether the doctor was called on Monday (06/27/22) .my expectation was that the nurse (LVN C) would call the doctor on Monday .but I did not call the doctor .given the toe was only swollen . During an interview on 06/29/22 at 9:57 AM, LVN C (former wound nurse-), stated, on 06/26/22 LVN (B) told me that Resident (#1's) left great toe was swollen .I told her that I had no doctor's orders and she should call the doctor .I did not call the doctor because I expected her (LVN B) to call the doctor . During an interview on 06/29/22 at 10:15 AM, CNA G, stated, I worked with Resident (#1) on 06/25/22 and 06/26/22 I provided Foley care (empty the bag), assisted with feeding for two days and resident (consumed) his food, no bathing that day .I did see his (Resident #1) left big toe .it was swollen and a little red and there might have been some dried blood on the toe I told the treatment nurse (LVN C) after hours on the drive home with her around 5:40 PM and she told me to inform LVN B which I did the next day (06/26/22) around 9:00 AM . [CNA G could not recall LVN B's response]. During an interview on 06/29/22 at 2:35 , the MD A, stated, I saw the Resident (#1) on 6/20/22 and ordered a nurse wound assessment [found in the H&P as a written ordered] because the resident was in general pain and had a wrapping on his left foot and bandage to right elbow when he arrived .I was never called between 06/20/22 to 06/27/27. Later I found out by the covering physician that the resident's left great toe was amputated .the failure as I see it was not following doctor's orders and the nurses not communicating between each other . During interview on 06/29/22 at 5:13 PM, MD A stated, if the nurse (LVN B ) had called me, I would have directed for a full assessment of the left great toe to determine whether the bone was showing. If the bone was showing or there was an infection, given it was the weekend, I would have ordered the resident being sent to the hospital for a foot examination or an x-ray . During an interview on 06/29/22 at 5:55 PM, the Administrator was notified of the IJ and the IJ template was provided to the Administrator. During an interview on 07/01/22 at 1:44 PM, DON stated, involving quality of care the nurses did not respond appropriately .I do not understand why .the nurses failed to collaborate as to who was going to call the physician .they did not call me .they assumed .regarding the initial care plan not done .they might have been in a hurry and did not follow the normal process for an admission .they rushed but were trained on wound care and admission process and notifying the MD .the process for admission is to do a skin assessment [within 48 hours of admission] .and to notify the physician if there are issues .[Assessment was a complete head to toe skin assessment. Facility procedure was for a second nurse to check the assessments and develop a baseline care plan . During an interview on 07/01/22 at 2:10 PM, the Administrator stated, in reference to quality of care there was a breakdown of communications and the procedures we have were not followed .for instance, the admitting nurse should have done a full initial assessment which included skin assessment and any orders uploaded to PCC .either the admitting nurse forgot the process or was in a hurry or distracted .there was a breakdown in communications and I cannot explain why the MD was not called .the process was not done for the initial care plan .the process was not followed .regarding lack of competencies probably stems from not following the process for initial care plan and skin assessment and when to notify the MD . Record review of facility's Grievance Log for the month of June 2022 revealed, a family member filed a grievance involving Resident #1 on 06/28/22. The family member was concerned about Resident #1's elbow and (left) great toe issues and wanted an update. Record review of facility's Wound Care policy, revised 07/2015, read, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order for this procedure . [policy did not address when to complete skin assessments and to notify the physician of any change of condition] FACILITY PLAN OF REMOVAL - Received and approved 06/30/22 at 11:07 AM from the Facility Administrator. On 07/01/22 at 3:30 PM, the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal. Facility's POR: The [facility's name] Nursing and Rehabilitation Center June 29, 2022 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On June 29, 2022, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: F584 Quality of Care Facility failed to provide a resident treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices to prevent an infection to the left great toe which included: failure to do a full head to toe assessment, failure of nursing staff to observe the residents left foot as ordered by the physician six days after admission when a nurse aide notified nursing staff that the resident's left great toe, and failure to train nursing staff on completing full skin assessment on admissions and as required for 1 of 5 residents reviewed for prevention of pressure ulcers. Resident #1 no longer resides in the center. The Licensed Nurses performed 100% skin rounds on residents on June 29, 2022, to establish a baseline for residents' skin integrity. The MD and responsible party were notified if not previously completed. Treatment orders were reviewed and obtained if not in place. The care plan was reviewed and updated if not present for each resident with identified skin alteration. The Director of Nursing or designee-initiated re-education for Licensed Nurses began on 6/29/22 regarding the following policies: o Pressure Injury Prevention that includes completion of assessment upon admission, having and following orders for skin alteration o Notification of changes o Abuse and neglect Re-education will continue until 100% of staff have completed the education. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Re-education will be completed by 6/30/2022. New admissions will be reviewed in the morning clinical meeting, attended by the Interdisciplinary Team, to ensure that an assessment was completed on admission, if skin alterations are present, that there is an order and care plan in place. The Director of Nursing or designee will review the 24- hour report in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. The Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the admissions and the 24-hour report in the morning clinical meeting. An AdHoc QAPI was conducted on June 29, 2022, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning pressure ulcers and to develop the above-mentioned plan of care. Administrator [NAME] Nursing and Rehabilitation Monitoring and confirmation interviews: Item: ---Resident #1 is no longer in the Center: Record review of facility's discharge list for the month of June 2022 revealed, Resident #1 was sent to a local hospital on 06/28/22 at 3:17 PM. Observation on 06/28/22 of Resident #1 revealed he was in a hospital bed at a local hospital ---In-service on Pressure Injury Prevention, Notification of Changes, and Abuse & Neglect; 1.During an interview on 06/30/22 at 11:51 AM, LVN C (Day shift) stated, make sure of re-positioning and do timely skin assessments .notify MD immediately and documents changes in condition .on neglect to provide the services a resident's needs . 2.During an interview on 06/30/22 at 11:54 AM, Social Worker (day shift) stated, if we have concern or unusual report immediately to the nurse .immediately notify the nurse and the nurse should do an assessment and notify MD .types of abuse was explained . 3.During an interview on 06/30/22 at noon, CNA H (night shift) stated, repositioned resident every 2 hours and check skin for wounds and redness .notify nurse immediately concerns with skin issues .need to report and abuse and neglect immediately to the Administrator . 4.During an interview on 06/30/22 at 12:02 PM, CNA I(day shift) stated, .proper placement of resident to prevent wounds and pressure .report when you see a difference in the skin immediately to the nurse .report abuse and neglect immediately to the Administrator . 5.During an interview on 06/30/22 at 12:06 PM, LVN J ( day shift) stated, look for changes of the skin .if required report to the MD to prevent further injury .report suspicions of abuse or neglect to the Administrator immediately . 6. During an interview on 07/01/22 at 11:50 AM, LVN F (day shift) stated, major highlights were to do good assessments, notify MD with any change of condition, and report any allegations of abuse and neglect . 7. During an interview on 07/01/22 at 11:59 A, Housekeeping K (day shift) stated, in the training I was told to report any falls to the nursing staff and any abuse .if you see skin tears report to nursing .and report any abuse to the Administrator. 8. During an interview on 07/01/22 at12:05 PM, CNA L (day shift) stated, the main highlight of the training was to report abuse/neglect and any changes in skin and skin tears and wounds to nursing . 9. During an interview on 07/01/22 at 12:08 AM, RN M (day shift) .follow the doctor's orders, follow the treatment plan, and report changes of condition to MD and family . 10. During an interview on 07/01/22 at 12:10 AM, LVN N, (day) I learned to do a thorough assessment on admissions, verify if an abnormality are found report to MD, follow treatment orders .and do thorough skin assessments. 11. During an interview on 07/01/22 at 12:54 PM, CMA O (night shift) , stated, highlights of training were that if I notice any wound issues notify nursing staff .any signs of abuse and neglect report to the Administrator withing 2 hours . 12. During an interview on 07/01/22 at 12:57 PM, , CNA G (night shift) stated, the highlights of the training on wound care were to report any skin changes to the nurse and fill an incident report and document in PCC .there are different types of abuse and neglect and report any suspicions to the Administrator immediately . 13. During an interview on 07/01/22 at 1:01 PM, LVN P (night shift) stated, I learned from the training that if the treatment is not working or there is a change of condition to call the MD and RP .do head to toe assessments at admissions and weekly .update the CP based on any changes in condition .the MD should be notified immediately after you are done with the skin assessment if there concerns about the skin .and do measurements and document .and report any abuse/neglect to the administrator. 14. During an interview on 07/01/22 at 1:07 PM, LVN Q, (day/night shift) stated, .the top three things I heard about wound care were to check wounds and check for infections, notify doctor and family when you see redness or signs of infection and follow doctor's orders .at admissions do a thorough skin assessment and document .always report abuse and neglect to the Administrator . 15. During an interview on 07/01/22 at 07/01/22 at 1:13 PM, CNA R (day/night shift) stated, .at the training I understood that when you see skin tears, infections or bruises report immediately to the nurse and document in PCC .on abuse and neglect that we should be able to recognize the signs and to report to the Administrator . Record review of facility's staff list dated 06/28/22 revealed 75 staff on payroll. Record review of facility's in-service sign in sheets on 07/01/22 revealed, the staffing number was 75 with 7 staff listed as PRN; minus the PRN staff, 100% of staff for both the day (6AM-6PM) and the night (6PM-6AM) shifts had attended a session of the in-service training. ---New Admissions During an interview on 06/30/22 at 12:20 PM, the DON stated, there have been no new admissions from 06/28/22 to 6/30/22; the last new admissions was on 06/27/22 (Resident #7) The resident self-discharged the next day. Per the POR, we will ensure a skin assessment is present and an initial care plan is completed. This will be monitored by the charge nurse and I will re-check the admissions packet for every new admission. ---24-hour report During an interview on 06/30/22 at 12:20 PM, the DON stated, we will discuss the 24 report at morning meeting which was done today (06/and discuss any changes and the need to contact the physician and RP or family member . Record review of 24 report revealed it was located in PCC under the heading Order Listing report. ---QAPI During an interview on 06/30/22 at 12:20 PM, the DON stated, the next QAPI meeting is scheduled for the third Thursday of the month ( 07/21/22) and a topic to be address is compliance with the POR. ---Administrator/Morning Meeting During an interview on 06/30/22 at 12:41 PM, the Administrator revealed he will attend morning clinical meetings staring July 1, 2022 except on weekends when no official morning meetings are held. During an interview on 07/01/22 at 10:40 AM, the Administrator revealed he attended the clinical morning meeting on 07/01/22 at 9 AM. The topics discussed, according to the Administrator included, labs, Medicare days and new orders. During an interview on 07/01/22 at 10:45 AM, the DON confirmed that the Administrator was present at the morning meeting. ---Skin Assessments and CP review Record review of sample residents with wounds ( Resident #2, #3, #4, $5, and #6,) revealed , CP addressed skin assessments that were done and CP reflected wound care interventions. ---System Process Record review of Nurse Note dated 6/29/22 at 6:38 PM (authored by LVN C ) revealed, wound assessment was done on 06/29/22 and Resident #2 wounds increased in area of the right foot/ankle and the physician was notified and new orders issued. The physician assessed the resident on 06/29/22. The RP was also notified. The physician's new order was paint with [MEDICATION(S)] and leave open to air. 22 [MD called on 6/29/22 because the resident had more areas of wounds; resident has vascular disease] Record review of Nurse Noted dated 6/29/22 at 8:29 PM authored by RN S, revealed new skin assessments and MD was notified and ordered was given. Record review of Resident #2's CP, dated 06/29/22, revealed the CP was updated to reflect the resident had an arterial/ischemic ulcers (related to vascular insufficiency); and interventions included to monitor/document wound. Record review of Residents' updated skin assessments (residents with wounds) revealed the dates of the updated skin assessments were: Resident #3-06/29/22 Resident #4-06/28/22 Resident #5-06/28/22 Resident #6-06/28/22 Review of facility's policy, Change in a Resident's Condition or Status (undated) read Our facility should promptly notify a resident, his or her attending physician and responsible party, of changes in the resident's medical/mental condition and or status). b. A significant change in the resident's physical, mental, or psychosocial status (i. e. a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). c. A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or D. A decision to transfer or discharge the resident from the facility. On 07/01/22 at 3:30 PM, the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #1) reviewed for quality of care, in that: Facility staff failed to provide necessary respiratory care to Resident #1 during an episode of acute respiratory distress, and delayed contacting 911 emergency medical services for more than 3 hours. This delay resulted in Resident #1 passing away at the facility. This failure resulted in the identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy was removed on [DATE], the facility remained out of compliance at actual harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR (Plan of Removal). This failure could affect residents experiencing an acute change in condition and place them at risk of not receiving necessary emergency care and services and could result in health decline, and/or death. The findings were: Closed record review of Resident #1's face sheet, undated, revealed resident was a [AGE] year old female with an admitted [DATE], and re-admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS of ,d+[DATE] indicating the resident was cognitively intact. Further review revealed the resident was usually understood and able to make herself understood. And resident was an extensive 2-person physical assist for bed mobility, turning side to side, changing positions in bed, and personal hygiene. Resident received oxygen therapy and suctioning, and experienced shortness of breath upon exertion, sitting at rest, or lying flat. Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .,d+[DATE].5 ([MEDICATION(S)] 0.5 mg-[MEDICATION(S)] 3 mg (also called [MEDICATION(S)]) (2.5 mg base) - medication combination used to relax muscles in the airways and increase air flow to the lungs to treat and prevent symptoms of wheezing and shortness of breath caused by ongoing lung disease) (3) mg/3 ml solution inhale 3 ml every 6 hours. Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's care plan undated revealed on the top of the first page Special Instructions: CALL TIHP / ISNP (Texas Independence Health Plan/Institutional Special Needs Plan) NURSE PRACTITIONER FIRST FOR CLINICAL CHANGES AND/OR ORDERS, (NP D and telephone number) . Closed record review of Resident #1's care plan revealed a focus initiated on [DATE] that resident was a Full Code with a goal for facility to comply with resident and family wishes. Closed record review of Resident #1's care plan revealed a focus initiated on [DATE] for (Resident #1) is at risk for ineffective breathing pattern related to DX (diagnosis): [CONDITION(S)], Pulmonary Fibrosis, Pulmonary [CONDITION(S)], [CONDITION(S)], & Allergic Rhinitis. HX (history) recurrent Pleural Effusion (A buildup of fluid between the tissues that line the lungs and the chest), [CONDITION(S)]/Pneumonia, Sinusitis & Respiratory failure. She has voiced feeling short of breath while lying flat, at rest and occasionally with exertion. She requires routine & PRN nasopharyngeal suctioning. And interventions included to give nebulizer treatments, incentive spirometry and oxygen therapy as ordered, and monitor vital signs as directed and as needed, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicate [CONDITION(S)] (low oxygen level in body tissues). Closed record review of Resident #1's care plan revealed a focus initiated on [DATE] for at risk for aspiration with interventions which included to Notify MD/family if suctioning is not effective in clearing airway, and oxygen and breathing treatments as ordered with pre and post assessments. Closed record review of Resident #1's EMAR (Electronic Medication Administration Record) for [DATE] revealed resident's oxygen saturation levels on 4 LPM ranged from ,d+[DATE]% and pulse ranged from ,d+[DATE] beats per minute. Closed record review of Resident #1's EMAR (Medication Administration Record) for February 2022 revealed resident's oxygen saturation levels From February 1st to the 25th ranged from ,d+[DATE]% and pulse ranged from ,d+[DATE] beats per minute and lung sounds were clear. Further review revealed on February 26th at 8:00 a.m. before administration of [MEDICATION(S)] Resident #1's oxygen saturation was 82% with a heart rate of 115 beats per minute, lung sounds were clear, and respirations were normal at 20 breaths per minute. And after administration of [MEDICATION(S)] at 8:00 a.m. Resident #1's oxygen saturation was documented at 80% with a heart rate of 110 beats per minute and documented lung sounds were clear and respirations were normal at 20 respirations per minute. Closed record review of Resident #1's EMAR (Medication Administration Record) for February 2022 revealed scheduled nasopharyngeal suctioning at 6:00 a.m. was completed and no as needed suctioning was documented for [DATE]. Closed record review of Resident #1's EMAR (Medication Administration Record) for February 2022 revealed [MEDICATION(S)] 20 mg one time ordered [DATE] at 8:45 am is documented not given at 12:08 p.m. as 7 Sleeping-see progress notes. Closed record review of Resident #1's progress notes revealed a comprehensive health record note dated [DATE] that resident was alert and oriented x 4 (person, place, month, year) without cognitive impairment, able to make her needs known, and respiratory status was stable, oxygen saturation was 99% on room air but that resident was on oxygen at 2 LPM via nasal cannula and was oxygen dependent. Further review revealed resident wanted to remain a full code and ok was typed in for hospitalization , intravenous fluids, blood [CONDITION(S)], [CONDITION(S)], diagnostic tests, feeding tube, labs, and surgery. Respiratory rate was regular and even, lungs were clear to auscultation throughout with diminished bases bilaterally. Continue oxygen at 4 LPM and triturate oxygen to keep oxygen saturation greater than 92%. Closed record review of Resident #1's progress notes revealed a monthly comprehensive note dated [DATE] that resident complained of intermittent burning pain that radiated from the back of the left knee down to her left foot but had no pain at time of assessment. Resident was alert and oriented x 4 (person, place, month, year) without cognitive impairment, able to make her needs known, and respiratory status was stable, oxygen saturation was 98% on room air but that resident was on oxygen at 2 LPM via nasal cannula and was oxygen dependent. Further review revealed resident wanted to remain a full code and ok was typed in for hospitalization , intravenous fluids, blood [CONDITION(S)], [CONDITION(S)], diagnostic tests, feeding tube, labs, and surgery. Respiratory rate was regular and even, lungs were clear to auscultation throughout with diminished bases bilaterally. Continue oxygen at 4 LPM and triturate oxygen to keep oxygen saturation greater than 92%. Closed record review of Resident #1's progress notes revealed a social service note dated [DATE] that resident remains a full code. Closed record review of Resident #1's progress notes revealed a note with an effective date of [DATE] at 6:42 a.m. by LVN C O2 57% when this nurse entered room. Turned oxygen up to 5. Duo neb breathing TX. (treatment) Oxygen fluctuating between 57% and 77%. Pulse ,d+[DATE]. Spoke with NP E from ISNPs. Was told to do breathing TX. Suctioned resident had very little secretions. Resident is very nervous and breathing fast. Head of bed is raised up with resident sitting straight up in bed. NP E ordered stat chest x-ray and (blood work). Closed record review of Resident #1's progress notes revealed a note with an effective date of [DATE] at 6:06 p.m. by RN B read 9:55 am this nurse in to draw blood. Resident appears cyanotic around lips and nose. Fingertips also cyanotic. Resident stated that her breaths felt heavy and that she was SOB (short of breath). O2 73% on 5l/NC (5 liters per nasal cannula). Resident placed on 10 L/facemask and O2 90%. Lungs diminished throughout with minimal air flow. Audible gargling noted. 10:05 a.m. this nurse instructed charge nurse to call TIHP/ISNP on call and receive order to send resident to ER for eval and TX for low O2 and call 911. Charge nurse called 911 at 10:11 a.m. Resident's O2 fluctuating between 70's - 80's. This nurse went for crash cart while charge nurse remained in the room. Non-rebreather applied at 15 liters. O2 continued to drop into the 60's and the 50's. Carotid pulse still palpable, HR 70. Breaths deep and labored. 10:20 a.m. Resident started to lose consciousness. 10:21 a.m. No breaths noted and no carotid heart rate palpable. CPR initiated. 2 rounds complete when EMS arrived and took over. Several rounds of IV sodium [MEDICATION(S)] and epi pushed by EMT. CPR continued during all of this time. 10:41 a.m. ER Dr. (name) called by EMT and stated to do one more round of epi and then pulse check. 10:46 a.m. pulse check and AED check resulted in no heartbeat detected. No breaths noted and resident cool to touch and cyanotic. Time of death 10:46 a.m. 10:50 a.m. Charge nurse updated family and TIHP/ISNP on call. 10:55 a.m. CNA X 3 performed postmortem care. Closed record review of Resident #1's progress notes revealed a note with an effective date of [DATE] at 7:22 p.m. by LVN C 8:07 am Called ISNPs again and told NP E that oxygen was fluctuating between 68% up to 80%. O2 stayed up at 80% to 88% while this nurse was in the room. 8:14 a.m. called ISNPs to let her know the oxygen was staying in the 80's. RN in room at 9:55 a.m. to draw blood oxygen was low again. A full mask with oxygen set at 10 liters was put on resident. O2 came up. At 10:09 a.m. this nurse entered room and resident's lips were blue O2 was at 57%. Called ISNPs again and told to send her out. Called 911 at 10:11 a.m. In the room with resident oxygen was fluctuating from 57% to 68% then started dropping. CPR started at 10:21 a.m. by RN. Review of Resident #1's cell phone and call logs revealed the facility was listed in the resident's contact list as Green with the main number for the facility listed and on [DATE] Resident #1 had a call out to the facility's main number at 4:26 am [MEDICATION(S)] 36 seconds. And another call out on [DATE] at 5:55 a.m. that lasted 47 seconds. Review of Resident #1's cell phone and texts revealed outgoing texts to Family member G on [DATE] at 8:34 a.m. If you can get her ID G, 8:36 a.m. Sweetheart. I need you. Please get up, 8:44 a.m. OK Google, and 8:46 a.m. , PS3. In a telephone interview on [DATE] at 2:51 p.m. CNA A stated she worked at the facility for about 3 years but quit due to shortage of staff and other problems. CNA A stated she worked on [DATE] from 6 a.m. to 6 p.m. She reported to work about 6 AM and checked in on Resident #1 at about 6 a.m. She stated Resident #1 was awake and requested to speak with the nurse because she was having trouble breathing. CNA A stated she immediately passed on the information to LVN C and LVN C told her she already knew and had been dealing with it. CNA A stated her next encounter with Resident #1 was about 9 a.m. when she fed the Resident breakfast. Resident #1 ate/drank about 25%. CNA A stated usually Resident #1 ate 100% of breakfast. CNA A stated the nurse came in to check on the Resident during breakfast time. Resident #1 told LVN C she was feeling short of breath and still feeling bad. CNA A stated LVN C was in the room for about 15 minutes. She stated she took a break from 9 a.m. to 10 a.m. and upon her return EMS was on sight. CNA A stated she did not hear Resident #1 making any calls while she was in the room and stated the Resident did not express any concerns to her. CNA A stated it was common for Resident #1 to ask for a nurse for suctioning or to ask about physician orders. CNA A stated LVN C was with Resident #1 most of the morning and she did not believe there was a delay in care. In an interview on [DATE] at 4:37 p.m. LVN C stated she worked at the facility for 10 months. LVN C stated she had reviewed her nurse's notes and had 43 residents on [DATE] and stayed very busy. LVN C stated on [DATE] at 6:42 a.m. was the correct date and time that she found Resident #1 with an oxygen saturation of 57%. LVN C reported she was having a conversation with Resident #1 and trying to calm her down and distract her because she was nervous about O2 reading. She reported Resident #1's skin was a pale white but normal skin color for the Resident. Resident #1 was already on 2 or 4 liters per minute of oxygen when she turned it up. LVN C reported she immediately sat Resident #1 up higher in the bed; turned the oxygen up to 5 LPM and talked with the Resident for a minute. LVN C stated she left the room and called the on-call NP, NP E. She reported she was unsure of the time but thought she called NP E at 7:11 a.m. and NP E told her to try a breathing treatment. LVN C stated she started with [MEDICATION(S)] and then did [MEDICATION(S)]. LVN C reported she suctioned Resident #1 after the first time she talked with NP E because after breathing treatments it usually brought up secretions. LVN C stated Resident #1's oxygen saturation was fluctuating but staying in the 70's. LVN C stated 70's was still low but Resident #1 was still talking and having conversations with her. LVN C stated Resident #1 was nervous and breathing fast, but she did not count her respirations. She further stated Resident #1's pulse would get up high (100 to 109) at times and this had happened before with Resident #1 after breathing treatments and suctioning. LVN C stated she was back and forth into Resident #1's room and asked CNA A to check in on Resident #1. LVN C stated she would go do something and then would return to check on Resident #1. LVN C stated Resident #1 would get nervous and she would calm her down by talking to her and telling the Resident she was going to call the doctor. LVN C stated at 8:17 a.m. Resident #1's O2 saturations were fluctuating between 64 and 88 % and she started a breathing TX. She called NP E and she ordered another breathing treatment. LVN C stated that NP E did not tell her she had the option to put a non-rebreather mask on Resident #1. Resident #1's O2 was going up slowly and it reached 88% and fluctuated back down. LVN C reported she notified RN B about Resident's #1 O2 level and STAT orders. RN B stated she was on her way but was unsure what time she notified RN B. LVN C stated STAT orders on the weekends could take up to 4 hours and she let NP E know at 8:14 a.m. and NP E said it was ok. She stated the STAT labs were never drawn. LVN C reported the O2 saturations were staying up in the 80's after the 2nd breathing treatment. She reported Resident #1 was not nervous anymore and vitals had improved but she did not document them. LVN C further reported the nurses were instructed to call ISNP first but would call 911 if she had felt it was an emergency. Reported Resident #1 did not lose consciousness until the end. LVN C reported RN B had to go and get another oxygen concentrator because the one in the room only went up to 5 liters and it took RN B about 5 minutes to return with the other oxygen concentrator. LVN C reported when RN B entered the room LVN C had also entered the room and Resident #1's lips were purplish, and her lungs sounded wet. LVN C stated it was normal for Resident #1 to have secretions and her lungs to sound abnormal. LVN C stated Resident #1 was still talking to her. LVN C stated that RN B had instructed her to call the NP and not 911 and then the NP told her to call 911. LVN C stated she called the NP and then called 911. Then she went back into the Resident's room and Resident #1's O2 SATs were fluctuating between ,d+[DATE]% and dropping. LVN C stated she was comfortable with NP E's orders and did not feel there was a delay in calling 911. LVN C stated that due to the length of time Resident #1's oxygen was below normal and below her baseline but again stated she did not feel she needed to call 911. LVN C further stated she had never seen Resident #1's oxygen saturations drop to 50's or 60's before. In an interview on [DATE] at 5:00 p.m. RN B stated LVN C called her and notified her that Resident #1's oxygen level was at 57% but was unsure of the time she was notified. RN B stated she instructed LVN C to call NP on call for orders and to try and get the Resident sent out. RN B reported when she arrived at the facility she attended to other residents and did not think Resident #1 would still be in the facility. LVN C later told her Resident #1 was still in the facility and had not been sent to the ER. RN B stated at 9:55 a.m. she went to draw the blood work for Resident #1. Resident #1 was trying to answer a phone call from a family member when she entered the room. RN B stated she noted Resident #1 was short of breath and O2 saturations were at 73% on 5 LPM of oxygen, was cyanotic around her lips, nose, and fingertips. RN B stated she went to grab another concentrator to increase oxygen because Resident #1 needed extra help. RN B stated she grabbed the crash cart and put Resident #1 on a face mask, rebreather, at 10 LPM and her O2 saturations increased to high 80's and up to 90%. RN B stated Resident #1's was anxious and talking but her voice was weak, and she told RN B I can't breathe, I need help and she told Resident #1, I'm helping Ms. [Resident's name]. RN B stated she told LVN C to call NP and 911. RN B stated Resident #1's saturations were 70%, deep and labored. They dropped to the 50% and then she coded. RN B stated she started first round of compressions when the EMT's arrived, and they took over and worked on Resident #1. RN B stated Resident #1 died in the facility later that morning on [DATE]. RN B stated it was obvious Resident #1 needed a higher level of care and needed to go to the hospital. She stated the facility was not equipped to provide ICU level of care and LVN C would not have known how to put the regulator on the oxygen that provided 10 liters of oxygen. RN B stated nursing staff had always been instructed to call NP before calling 911. She further stated on call ISNP staff was not 100 % knowledgeable about facility protocol regarding the fact that STAT labs could take up to 4 hours. RN B stated there was no doubt Resident #1 had been in respiratory distress and should have been sent out to the hospital at the time LVN C noted Resident #1's saturations were at 57%. In a telephone interview on [DATE] at 2:17pm NP E with TIHP/ISNP stated she was the NP on call the morning of [DATE]. She stated she was not familiar with Resident #1 but had access to PCC (Point Click Care-computer system used for EHR for residents). She reviewed the first contact note at 7:33 am with LVN C and stated she had missed a call from LVN C right before and she called her right back. NP E stated LVN C reported Resident #1's O2 saturations were at 57% but stated that was not a true oxygen saturation reading with a pulse oximeter, and she verified the nurse had access to nebulizer treatments. NP E stated the nurse had reported Resident #1's heart rate of ,d+[DATE] and rapid breathing but did not give a number of respirations per minute. NP E stated she instructed LVN C not to wait for her next ordered breathing treatment and to give them back-to-back and to suction Resident #1 because with the Resident's history and breathing treatments ordered she felt the Resident had a mucous plug and would be fine once she cleared it. NP E again stated she had access to PCC and was looking in Resident #1's record. NP E stated she called the nurse back at 8:07 am and the nurse informed her that the Resident was improving and O2 saturations were ,d+[DATE]% on 5 L/LPM of oxygen and showed significant improvement. She told LVN C she needed a full set of vital signs the next time she spoke with her and ordered the CPT vest to be used, STAT [MEDICATION(S)] X 1 and a STAT chest x-ray. NP E further stated she told the nurse she could also use a mask for oxygen if needed. She stated she received a call from the nurse at 8:15 am stating the CXR would be an hour and she told her an hour was ok since the Resident was improving and her O2 saturations were now ,d+[DATE]%. She stated she did not feel that 911 should be called due to the Resident having significant improvement. NP E confirmed she did see the Resident's baseline vital signs and her O2 saturations were normally ,d+[DATE]% and stated Resident #1 had improved. NP E stated her timeline was 45 minutes not 2.5 or 3 hours. NP E stated she had no further communication from LVN C until she was called at 10:06 am and 911 was called. When asked if she knew anything about the nurses being instructed to call the NP first before calling 911, she stated that the nurses might be referring to their program protocol to reduce unnecessary ER visits and hospitalization s for things that could be treated at the facility but that she would and has sent residents to the hospital. NP E stated she did not feel 911 should have been called earlier from the information she had at that time. In a telephone interview on [DATE] at 2:53 PM with NP D stated she was the normal NP for Resident #1 but was not on-call the weekend of [DATE]. NP D confirmed she had read the notes from the on call NP E and stated that immediate interventions were completed, and Resident #1 was improving. NP D further stated that when she returned on Monday the facility staff informed her that Resident #1 had been awake, alert, sitting up in the bed and texting her family for 2 hours during the episode. NP D could not recall what staff had told her the Resident was texting her family for 2 hours during this episode. NP D stated Resident #1 had refused suctioning in the morning prior to this episode. NP D stated that she had attempted to contact the family but did not receive a call back and was unable to attend a meeting the Resident #1's family had with the facility the following Monday on [DATE] as she was unable to get to the facility in time and she understood the family was grieving. NP D stated she was unable to state if she would have instructed staff to call 911 because she was not the one on call but based on the information provided in the NP notes, NP D agreed based on the information provided to the NP that 911 was not needed prior to being called. Interview on [DATE] at 11:45 AM revealed RN B stated LVN C called her between 7:30 and 8 AM. She instructed LVN C to call the NP and try to get orders to send Resident #1 out. LVN C told her Resident #1's saturations had been in the 70's but were better and in the 80's but she still instructed LVN C to call ISNP to try and send Resident #1 out. RN B stated she thought Resident #1 was going out and was surprised Resident #1 was still in the building. RN B stated she arrived at the facility between 9:30 to 10 AM. RN B stated she had a scheduled lab draw that morning and took care of that before she talked to LVN C. She stated that's when she realized there was a STAT order for labs. She stated she reminded LVN C that on weekends it could take up to 4 hours for a STAT lab (because they had to draw and take it to the hospital) and to call ISNP to clarify. Interview on [DATE] at 12:05 PM with the DON revealed she provided an in-service on [DATE] re: ISNPs protocol but also emphasized that in an emergency nursing staff should use their best nursing judgment. The DON stated staff was in touch with her the morning of [DATE] but could not remember the time and stated she had several conversations with staff when Resident #1 was receiving CPR. Interview on [DATE] at 12:09 PM with LVN C revealed she clarified that she called RN B between 7:,d+[DATE] AM and told her everything that was going on with Resident #1. She also let RN B know about the STAT labs. She stated she had already called the NP about the Resident's condition. LVN C denied CNA A notified her that Resident #1 stated she was having trouble breathing or communicating to CNA A that she already knew and was dealing with it. LVN C stated she was not sure if Resident #1 called the nurse's desk that morning but might have been that morning that she requested to get changed. Again, she stated she was not sure but stated it was not uncommon for Resident #1 to call the nurse's station for help. LVN C stated Resident #1 had also previously called to let staff know she needed suctioning. She stated Resident #1's saturations were between 80 and 88 % for a brief time while she was in the Residents room. LVN C stated she was in and out of the room and stated she did not notice Resident #1 on the phone and did not hear Resident #1 talking to family on the phone. LVN C stated Resident #1's 02-saturations went up to 90% for a brief time while RN B was working on her and then they quickly started dropping and then the EMT's arrived. LVN C stated Resident #1 expired the morning of [DATE]. In a telephone interview on [DATE] at 1:02 PM MD F stated he knew Resident #1 and her family very well and was very familiar with the Resident's history. MD F stated he had not reviewed the nurses notes from [DATE]. MD F stated 6:42 am to 10:11 am was an extended period of time for the O2 SATs to be below normal or below baseline for the Resident but he was unable to state that 911 should have been called or what he would have done because he was not on call and did not question the nurse himself as he might have had a different assessment. In a previous interview on [DATE] at 4:05 p.m. the DON stated Resident #1 had been in respiratory distress since initial assessment and based on the residents oxygen saturations she would have sent the resident to the ER. The DON stated she have wanted the resident's oxygen saturations to remain in the high 80's. In an interview on [DATE] at 12:17 PM with the DON revealed she had instructed staff to call ISNP to get directives when dealing with Resident's day to day illnesses, orders etc. since she hasbeen in her position as of [DATE]. However, she made it clear staff did not have to call ISNP to get permission to call 911. She instructed staff to use their professional judgement about sending a resident out when faced with an emergency. The DON stated nursing staff would call the NP instead of the physician when the resident was part of the ISNP group. The NP would call the resident's PCP to update him on their condition. The DON and Surveyor read the nurses note dated [DATE] and asked the DON what she would have done in this situation. It was documented Resident #1's 02-saturations fluctuated between 57 to 77 % and her pulse was between 110 to 115. The DON stated she was not on call and did not have the opportunity to ask other questions she normally would ask to get a clear picture of what was going on with Resident #1. However, confirmed Resident #1 was in acute respiratory distress based on the 02-saturation reading. The DON would not definitively say whether she would have sent Resident #1 to the hospital even though, during initial interview on [DATE], she stated she would have sent Resident #1 to the hospital. The DON stated LVN C called ISNP which was what she was supposed to do. She stated ISNP staff had a higher level of education than she did, and a broader level of understanding and training of what parameters were safe before sending a resident out. The DON stated the NPs were more in tuned with Resident #1's condition. She stated maybe NP E, who was on call, was not as in tuned with Resident #1, but stated she was not sure how much remote access NP E had to Resident #1's record. The DON stated she was not aware if Resident #1 called the nurse's desk on the morning of [DATE] but stated it was not unusual for the Resident to call the nurse's station and ask for help for whatever she needed. The DON stated she understood Resident #1 was also texting with family members on [DATE] but could not remember who told her. Review of facility change in a resident's condition or status policy revised ,d+[DATE] read . 4. Evaluate causes of change and intervene as indicated. 5. Evaluate interventions or monitor resident as indicated. Review of facility emergency physician care policy undated read . 1. Emergency physician care is available to all residents. In an emergency situation activate the emergency medical service (EMS 911). Review of the National Library of Medicine StatPearls updated [DATE] titled Pulse Oximetry read . Normal and Critical Findings- Oxygen saturation levels around 96% to 100% are considered normal at sea level . Pulse oximeters are usually calibrated to a range of saturation from 70% to 100% with an accuracy of 2% to 4%, which means that pulse oximeter is reading lower than 70%, may not be

Based on observation, interview and record review the facility failed to immediately inform the resident representative when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for 1 of 3 Residents (Resident #1) whose records were reviewed. LVN C failed to contact MD and notify Emergency Contact #1 when Resident #1 went into respiratory distress. This failure resulted in the identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy was removed on [DATE], the facility remained out of compliance at actual harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR (Plan of Removal). This deficient practice could result in representatives not having the opportunity to advocate for the residents. The findings were: Closed record review of Resident #1s face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #1 had an Emergency Contact #1 (family member). Closed record review of Resident #1's quarterly MD'S, dated [DATE] revealed her BIMS score was 15 indicating no cognitive impairment. Further review revealed other diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of Resident #1's care plan, revealed a focus initiated on [DATE] that resident was a Full Code with a goal for facility to comply with resident and family wishes. Closed record review of Resident #1's care plan, revealed a focus initiated on [DATE] for at risk for aspiration with interventions which included to Notify MD/family if suctioning is not effective in clearing airway, and oxygen and breathing treatments as ordered with pre and post assessments. Interview on [DATE] at 4:37 PM with LVN C confirmed she was the charge nurse on duty on [DATE] when Resident #1 experienced an episode of acute respiratory distress. She stated she thought she called Emergency Contact #1 when the paramedics were working on Resident #1. LVN C stated she could not remember and then stated Family Member G called after Resident #1 expired, and Family Member G that Resident #1 had expired and Family Member G told her she would call Emergency Contact #1. LVN C stated Family Member G was not listed on the face sheet as an emergency contact. LVN C stated she did not call Emergency Contact #1 at any other point during Resident #1's change of condition. She also confirmed she was responsible for calling Emergency Contact #1 and notify her that Resident #1 experienced a change of condition. LVN C stated Emergency Contact #1 was involved in Resident #1's care and would have wanted to know of any change in condition. LVN C confirmed not calling Emergency Contact #1 excluded her from advocating for Resident #1's treatment when Resident #1 went into respiratory distress. Interview on [DATE] at 10:03 AM with Emergency Contact #1 and Family Member G revealed Emergency Contact #1 was adamant that nursing staff did not call her when Resident #1 went into respiratory distress or when 911 was called. Emergency Contact #1 was visibly upset as evidenced by becoming tearful. Emergency Contact #1 expressed frustration and helplessness about not being notified and not being involved in the decision making when Resident #1 went into respiratory distress. Emergency Contact #1 stated nursing staff did not even notify her when Resident #1 expired. She stated Family Member G called her screaming and crying after learning Resident #1 had died . Emergency Contact #1 stated she was so upset about how nursing staff handled the situation. Interview with Family Member G confirmed she did not tell LVN C that she would notify Emergency Contact #1 about her passing. She stated she was distraught and crying when LVN C notified her Resident #1 had expired and hung up the phone soon after she learned of Resident #1's death. Interview on [DATE] at 12:09 PM with LVN C revealed she clarified that she called RN B between 7:,d+[DATE] AM and told her everything that was going on with Resident #1. She also let RN B know about the STAT labs. She stated she had already called the NP about the Resident's condition. LVN C denied CNA A notified her that Resident #1 stated she was having trouble breathing or communicating to CNA A that she already knew and was dealing with it. LVN C stated she was not sure if Resident #1 called the nurse's desk that morning but might have been that morning that she requested to get changed. Again, she stated she was not sure but stated it was not uncommon for Resident #1 to call the nurse's station for help. LVN C stated Resident #1 had also previously called to let staff know she needed suctioning. She stated Resident #1's saturations were between 80 and 88 % for a brief time while she was in the Residents room. LVN C stated she was in and out of the room and stated she did not notice Resident #1 on the phone and did not hear Resident #1 talking to family on the phone. LVN C stated Resident #1's 02-saturations went up to 90% for a brief time while RN B was working on her and then they quickly started dropping and then the EMT's arrived. LVN C stated Resident #1 expired the morning of [DATE]. In a telephone interview on [DATE] at 1:02 PM MD F stated he knew Resident #1 and her family very well and was very familiar with the Resident's history. MD F stated he had not reviewed the nurses notes from [DATE]. MD F stated 6:42 am to 10:11 am was an extended period of time for the O2 SATs to be below normal or below baseline for the Resident but he was unable to state that 911 should have been called or what he would have done because he was not on call and did not question the nurse himself as he might have had a different assessment. Review of facility policy, Change in a Resident's Condition or Status (undated) read Our facility should promptly notify a resident, his or her attending physician and responsible party, of changes in the resident's medical/mental condition and or status). b. A significant change in the resident's physical, mental, or psychosocial status (i. e. a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). c. A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or D. A decision to transfer or discharge the resident from the facility.

Based on interview and record review, the facility failed to ensure that based on a resident's comprehensive assessment that a resident maintained acceptable parameter of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 4 residents (Resident #1) reviewed for assisted nutrition, in that: 1. The facility did not monitor Resident #1's weights weekly per the dietitian's recommendations from 07/02/2020 to 07/31/2020 (29 days) and did not identify the resident's significant weight loss. 2. The facility did not identify that Resident #1 had significant weight loss - a loss of 11.8 lbs. from 07/07/2020 to 07/31/2020 (24 days) - after the resident's enteral feedings were discontinued on 07/07/2020. These deficient practices could place residents at risk for significant weight loss and a decline in overall medical condition. The findings were: Record review of Resident #1's face sheet, dated 08/01/2020, revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #1 was discharged from the facility on 07/31/2020. Record review of Resident #1's Significant Change in Status MDS, dated [DATE], revealed the resident had a BIMS score of 3, which indicated the Resident was severely cognitively impaired, and required set up, ADL assistance for eating, primary medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the Resident weighed 183 pounds at the time of the assessment, was on four antibiotics, and was on quarantine for active infectious disease (COVID-19). Record review of Resident #1's Care Plan, revised 07/24/2020, revealed the Resident's weight had declined since admission (admitting weight: 199.4), the Resident had a tube feeding placement but was no longer receiving tube feedings, and received water flushes and staff was to monitor the Resident's gastrostomy site. Further review revealed the Resident was a risk for deterioration of medical condition related to active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #1 was at risk for nutritional imbalance due to COVID-19, and staff was to monitor weights, provide diet as ordered, encourage compliance, provide snacks, document intake every meal, monitor lab results as ordered and notify the physician of malnutrition and any significant weight changes. Record review of Resident #1's electronic record revealed manual weights recorded as follows: - 04/08/2020 at 12:18 [12:18 p.m.] - 199.4 lbs. - 04/17/2020 at 16:54 [4:54 p.m.] - 192.0 lbs. - 04/23/2020 at 17:59 [5:59 p.m.] -189.8 lbs. - 04/29/2020 at 17:29 [5:29 p.m.] - 183.2 lbs. - 05/08/2020 at 12:58 [12:58 p.m.] - 181.0 lbs. - 06/04/2020 at 16:40 [4:40 p.m.] - 178.2 lbs. - 06/09/2020 at 17:20 [5:20 p.m.] - 173.8 lbs. - 06/11/2020 at 13:39 [3:39 p.m.] - 180.6 lbs. - 06/17/2020 at 16:25 [4:25 p.m.] -180.0 lbs. - 06/24/2020 at 14:26 [2:26 p.m.] - 181.4 lbs. - 07/02/2020 at 16:27 [4:27 p.m.] - 182.8 lbs. - Week of 07/06/2020 - there were no recorded weights - Week of 07/13/2020 - there were no recorded weights - Week of 07/20/2020 - there were no recorded weights - 07/31/2020 at 9:13 [9:13 a.m.] - 171.0 lbs. Record review of Resident #1's RD assessment, dated 04/28/2020, revealed: Tube feeding progress note: wt: 189.8 lbs., ht: 69 in, BMI 28.1 Weight changes: Non-significant -4.8%(-10#) x 30 days. Skin: No PI noted Rx: Reviewed Current diet order: NPO Current TF Regimen: 65 ml Glucerna 1.5 x 20 hour. Regimen will provide 1950 kcal, 107 g protein, and 2185 ml fluid. Estimated needs: 1510-1785 kcal (msjx1.25af), 86-104 g (1.0-1.2 g/kg), 2157-2588 ml (25-30 ml/kg). Resident actual needs exceed estimated needs due to weight loss. Per nurse charting, resident is tolerating current feedings well. Recommend to DC flush 100 ml q 2 hours. Increase TF regimen to 75 ml Glucerna 1.5 x 20 hours to provide 2250 Kcal, 124 g protein and 1140 ml fluid. Flush 150 ml fluid q 4 hours to provide 900 ml fluid, Total daily fluid is 2040 ml. Goal: good TF tolerance and no weight loss. Record review of Resident #1's RD assessment, dated 05/18/2020, revealed: Tube feeding progress note: wt: 181 lbs., ht: 69 in, BMI: 26.8 Weight changes: Significant weight loss - 9.2% (-18.4#) x 30 days. Skin: No PI noted Rx: Reviewed Current diet order: NPO Current TF Regimen: 75 ml Glucerna 1.5 x 20 hours regimen will provide 2250 kcal, 124 g protein, Flush 150 ml Q 4 hours to provide an additional 900 ml fluid, 2040 ml fluid daily. Estimated needs: 1466-1733 kcal (msj x1.25af), 82-99 g (1.0-1.2 g/kg), 2057-2468 ml (25-30 ml/kg). Resident noted with good tolerance to TF changes. No current weight since adjustments were made to TF a few weeks ago as a result of weight loss. RD will monitor weight. Continue current POC. Record review of Resident #1's RD assessment, dated 05/28/2020, revealed: Consult progress note: Wt: 181 lbs., Ht: 69 in, BMI: 26.8 Weight changes: Weight loss has slowed. Skin: No PI noted Rx: Reviewed Current diet order: NAS (No Added Salt) diet, Mechanical Soft texture, Regular Liquids consistency. Current TF Regimen: 75 ml Glucerna 1.5 x 20 hours regimen will provide 2250 kcal, 124 g protein, Flush 150 ml Q 4 hours to provide an additional 900 ml fluid, 2040 ml fluid daily. Resident with dietary change due to swallow study. Recommend to reduce TF to 75 ml Glucerna 1.5 x 8 hours nocturnal feeding to provide 900 kcal, 50 g protein, and 455 ml fluid. Flush 150 ml fluid q 6 hours to provide an addition 600 ml fluid, 1055 total. Offer snacks TID. Recommend weekly weights to assess if PO intake/TF is meeting needs or if further adjustments are needed. RD will follow up and make adjustments as needed. Record review of Resident #1's RD assessment, dated 06/08/2020, revealed: Tube feeding/Weight loss progress note: Wt: 178.2 lbs., Ht: 69 in, BMI: 26.4 Weight changes: Nonsignificant -3# weight loss x 30 days, Significant weight loss -10.6% (-21.2#) x 90 days. Skin: No PI noted Rx: Reviewed Current diet order: NAS diet, Mechanical Soft texture, Regular Liquids PO intake: 75-100% per nurse charting. Current TF Regimen: 75 ml Glucerna 1.5 x 8 hours to provide 900 kcal, 50 g protein, Flush 150 ml Q 6 hours to provide an additional 600 ml fluid, 1055 ml fluid daily. Resident with good PO intake and tolerating TF well. Resident is meeting needs. RD will monitor weight to ensure that weight loss does not continue. Recommend to continue current POC. Record review of Resident #1's RD assessment, dated 07/01/2020, revealed: Enteral Assessment: Weight 181.4 (lbs) date 6/24/2020 scale: Weight Changes: weight regimen after loss consistent with UBW. Diet: NAS Diet, Mechanical Soft Texture, Regular Liquids. % PO Intake: 75-100%. Supplement: Offer House Shake TID. Estimated Need: kcal 1468-1730 kcal (msj x 1.25 af). Protein: 82-99 g (1.0-1.2 g/kg, fluids 2061-2474 ml (25-39 ml/kg). Skin Integrity: No PI noted. Labs: no new labs available. Pertinent medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Flushes: 150 ml q 6 hours. Provided Calories: 900 kcal Provided Protein: 50 g protein. Provided Fluid: 1055 ml. Tolerance to TF: good, no issues. New Dietary Recommendations? Yes. Recommendations: good to good PO intake and accepting snacks, recommend to DC tube feed. Continue to offer snacks/shake TID. Monitor weight changes weekly x 4 weeks to ensure Resident is meeting need with PO intake. Plan of Care Updated: No. Record review of facility's log for COVID-19 Residents, undated, revealed Resident #1 tested positive for COVID-19 on 07/20/2020. Record review of Resident #1's consolidated orders for July 2020 revealed the resident's therapeutic diet included a NAS diet, Mechanical Soft texture, Regular Liquids, night TF 75 ml Glucerna 1.5 x 8 hours to provide 900 kcal, 50 g protein, Flush 150 ml Q 6 hours to provide an additional 600 ml fluid, 1055 ml fluid daily. In addition, Resident #1 was to receive snacks and health shakes three times a day at 10:00 AM, 2:00 PM, and 10:00 PM. Further review revealed the order for the night TF was discontinued on 07/07/2020. Record review of Resident #1's Skilled Administration Record for July 2020 revealed Resident #1 received a therapeutic diet, Mechanical Soft texture, Regular Liquids, night feeding TF 75 ml Glucerna 1.5 x 8 hours to provide 900 kcal, 50 g protein, Flush 150 ml Q 6 hours to provide an additional 600 ml fluid, 1055 ml fluid daily until 07/07/2020. Further review revealed that staff documented less than 50% of when Resident #1 received a snack and health shake especially on the 2:00 PM and 10:00 PM shifts per the blanks noted on the record. Record review of Resident #1's meal intake log for July 2020 revealed the resident ate 76 to 100% of her meals from 07/01/2020 to 07/15/2020 on the days staff documented. There were 11 days where there was no documentation on the 2:00 PM and 10:00 PM shifts. Further review revealed that from 07/16/2020 to 07/31/2020 Resident #1 continued to consume 76% to 100% on the days her intake was documented. Then there was a decline of consumption from 51% to 75% on 07/28/2020 until 07/31/2020. Further review revealed there were 5 days during this period there was no documentation and multiple days there was no documentation for the 2:00 PM and 10:00 PM shifts. Record review of Resident #1's hospital History and Physical, dated 07/31/2020, revealed: . female brought in by family after being discharged today from skilled nursing facility at [facility name]. They last saw her a couple of weeks ago and she was rehabilitating very well after [CONDITION(S)] surgery in March. She was felt to be 90% recovered as of 2 weeks ago. She succumbed to a breakout of COVID in the nursing home. She was empirically treated with [MEDICATION(S)] (a medication used to treat asthma) and [MEDICATION(S)] (a medication used to treat infection caused by parasites) and [MEDICATION(S)] (a medication used to treat inflammation) and [MEDICATION(S)] (a medication used to treat and prevent gout). She was discharged from the nursing home today. When family picked her up, they were stunned to see that her weight had dropped by 15 lbs. in the last few weeks. She was somewhat mentally confused and lethargic and weak. They brought her to the emergency room for evaluation. Further review revealed Plan read: Plan: 1. COVID-19 pneumonitis. Patient has already recently been treated with a cocktail of medications including [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]. 2. Weakness and lethargy and confusion, likely secondary to 1. During an interview with Resident #1's family member on 12/16/2020 at 12:31 p.m., Resident #1's family member stated she had on-going problems with follow-up and communication mostly from administrative staff throughout Resident #1's stay at the facility. The resident's family member stated staff reported that Resident #1 was walking, talking, and progressing without any problems every time she called during July 2020. The resident's family member stated they had a visit during the first part of July 2020 and Resident #1 was alert, walking, talking, and her weight looked good. Resident #1's family member stated that on 7/23/20 she called the facility and at that time staff informed her that Resident #1 tested positive for COVID and was moved to the COVID unit. The resident's family member stated the ADON reported to her that per CDC guidelines Resident #1 could be released from isolation after 10 days of being asymptomatic. The resident's family member stated 07/31/2020 marked the 10th day since Resident #1 was diagnosed with COVID-19 and the ADON and other staff reported Resident #1 had been asymptomatic. The resident's family member stated Resident #1 was discharged on [DATE]. The resident's family member stated she requested that staff weigh her before discharge and Resident #1 weighed 171 pounds. The resident's family member stated that at the time of discharge Resident #1 could not walk, could not talk, was lethargic, and the resident's eyelids were swollen. The resident's family member stated she took Resident #1 straight to the hospital in their hometown, from the facility on 07/31/2020 where Resident #1 was admitted due to debility and tested positive for COVID-19. During an interview with the SW on 12/17/2020 at 1:52 p.m., the SW stated he visited with Resident #1's family member at the time of discharge. The SW stated Resident #1 was sitting in the family member's car and he did not note that Resident #1 was lethargic. The SW stated the resident's family member told him she would be taking Resident #1 to the hospital because Resident #1 was lethargic, could not walk or talk, and she looked frail. The SW stated he did not see the deficits the family member reported. The SW confirmed Resident #1 had tested positive for COVID-19 and it may have, slowed her [Resident #1] down some. The SW stated he did not know about Resident #1's intake and when Resident #1's family called, he referred her to nursing staff with clinical questions. During an interview with the DON on 12/17/2020 at 3:30 p.m., the DON stated Resident #1 was critically ill upon admission. The DON stated Resident #1 made remarkable strides throughout her stay at the facility while receiving skilled services, however, Resident #1 had also experienced significant weight loss and was followed by an RD who provided nutritional guidance and recommendations. The DON confirmed Resident #1 tested positive for COVID-19 on 07/20/2020 and the facility received the results late evening on 07/22/2020. The DON stated Resident #1 was moved to the COVID unit where she was isolated. The DON confirmed that she notified Resident #1's family member about the test results and the Resident's move on 7/23/20. The DON stated Resident #1 was not eating as much when moved to the COVID unit however did not experience any ADL deficits. The DON stated Resident #1 was moved to the COVID-19 unit where she was isolated. The DON confirmed she notified Resident #1's family member about the test results and the resident's move on 07/23/2020. The DON stated Resident #1 was not eating as much when moved to the COVID unit however did not experience any ADL deficits. The DON stated Resident #1 accepted snacks and would consume some of her health shake with her medications. The DON confirmed Resident #1 had a tube feeding placement in the event the resident needed enteral feeding. The DON stated she did not see Resident #1 upon discharging from the facility. During an interview with the DOR on 12/17/2020 at 4:18 p.m., the DOR confirmed Resident #1 received skilled rehabilitative services throughout her stay at the facility including after Resident #1 was moved to the COVID-19 unit. The DOR stated the PTA reported Resident #1 was not walking and talking as much during isolation. The DOR stated upon discharge Resident #1 was stand by assist to minimum assist for ambulation upon discharge. The DOR confirmed Resident #1 had a tube feeding placement in the event she required enteral feeding upon discharge. The DOR stated Resident #1 received ST and the focus was to monitor the resident's PO intake. The DOR stated Resident #1 was able to feed herself, but the ST recommended that staff monitor, provide encouragement and assistance as needed once she started eating solid foods. During an interview with LVN B on 12/17/2020 at 5:18 p.m., LVN B stated she was the charge nurse at the time of Resident #1's discharge. LVN B confirmed Resident #1 was in the COVID-19 unit and the only symptom Resident #1 had was a non-productive cough. LVN B stated Resident #1 was a 1 person assist for ambulation; sometimes the resident was able to help more than other times with ADLs, and on some days the resident would talk more than on other days. LVN B stated she did not remember Resident #1 walking at the time of discharge and could not remember who assisted with the transfer into the family members car. LVN B stated Resident #1's family member did not express any concerns to her, however, then stated the resident's family member wanted an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated she did not note a change of condition at the time of Resident #1's discharge. During an interview with Resident #1's family member on 12/22/2020 at 10:49 a.m., Resident #1's family member stated she had expressed concern about Resident #1's decline in physical condition while in the COVID-19 unit, and stated staff was not reporting any changes. The resident's family member stated she had expressed concerns that staff had not continue to monitor Resident #1's weights after the enteral feeding was discontinued. The family member stated that Resident #1 was weighed upon her request upon discharge; Resident 1's weight was 171 lbs. The resident's family member stated Resident #1's weight on 7/2/20 was 182.8 lbs. The resident's family member expressed concern the facility did not use tube feeding once Resident #1 started losing weight. The resident's family member stated Resident #1 remained in the hospital until 08/14/2020. Resident #1's family member stated Resident #1 had lost all of the gains she made up until the family visit during the first part of July 2020. The resident's family member stated to date, Resident #1 required assistance with all ADLs. The resident's family member stated Resident #1 was not walking, talking and did not assist with ADLs. During an interview with the DON on 12/22/2020 at 1:27 p.m., the DON confirmed staff did not weigh Resident #1 during July 2020, and stated staff were not weighing the resident because the resident was on the COVID-19 unit and the scales were not movable. The DON further confirmed Resident #1 was not moved into the COVID-19 unit until 07/22/2020 and there was a two week lapse where Resident #1's weight was not taken. The DON stated staff had an opportunity to weigh Resident #1 on 07/20/2020 and 07/21/2020 before the resident was transferred to the facility's COVID-19 unit on 07/22/2020. During an interview with RD A on 12/22/2020 at 2:01 p.m., RD A stated it was standard practice to review all new admissions and follow residents receiving tube feedings monthly. RDA A stated staff would refer residents for consultation and recommendations when there was a weight loss. RD A confirmed she completed an initial assessment for Resident #1 on 04/13/2020 and then during May 2020 staff reported Resident #1 tube feeding was discontinued and the resident had experienced weight loss. RD A confirmed she provided a dietary consultation and recommendations on 05/18/2020, 05/28/2020, 06/08/2020, and then on 07/01/2020 to accommodate the weight variances. RD A stated that upon reviewing Resident #1's weights she noted that on 04/28/2020 Resident #1 lost 16 pounds; on 05/18/2020 the resident lost 2 more pounds; on 05/28/2020 Resident #1's weight was stabilizing, and she received an email from staff on this same date that Resident 1's tube feedings would be discontinued. RD A stated Resident #1's diet was NAS, MS, regular thin liquids. RD A stated staff was charting that Resident #1 was consuming 75 to 100% of her meals during June 2020. RD A stated on 06/08/2020 Resident #1 lost 2 more pounds, and she stated she recommended Resident #1 receive night feedings as the resident was transitioned to PO diet to prevent further weight loss. RD A stated Resident #1 gained 2 pounds from 06/11/2020 (180 lbs.) to 07/02/2020 (182 lbs.). RD A stated Resident #1's weight had stabilized. RD A stated on 07/01/2020 staff reported Resident #1 was accepting snacks and health shakes three times a day and at the time she recommended to discontinue the resident's night feedings and monitor weights weekly for 4 weeks for PO intake to ensure there was no weight loss. RD A stated this was her last consultation for Resident #1 and confirmed if Resident #1 had experienced weight loss again then nursing staff would refer Resident #1 back to her for consultation. During an interview with the DON on 12/22/2020 at 4:06 p.m., the DON stated she was not aware of RD A's dietary consultation for Resident #1, dated 07/01/2020, with recommendations which included weekly weights. However, the DON confirmed that Resident 1's night feedings were discontinued on 07/07/2020. The DON further stated that typically RD A would email her with a daily activity sheet with a list of Residents reviewed; would indicate if any of the Resident's weight was trending down and if the Resident was not receiving tube feedings to supplement their intake. During an interview with RD A on 12/22/2020 at 4:56 p.m., RD A confirmed she would email the DON with an activity sheet with the residents' information and recommendations whose charts she reviewed on the date of review. During an interview with the DON on 12/22/2020 at 5:14 p.m., the DON stated she clarified RD A did in fact provide a dietary consultation for Resident #1 on 07/01/2020. The DON stated she was on leave at this time and her duties were passed on to the ADON which included the ADON was to follow-up with RD A's recommendations, contacting the physician, getting orders to discontinue night feedings, and to monitor weights for four weeks, which the DON stated did not happen. The DON stated the ADON obtained an order to discontinue tube feeding but did not obtain an order to monitor weights for four weeks, which would have been transferred onto the consolidated orders for staff to follow. The DON confirmed Resident #1 had a significant weight loss of over 10 pounds from 07/02/2020 to 07/31/2020. The DON confirmed Resident #1's weight on 07/02/2020 was 182.8 pounds and on 07/31/2020 it was 171 pounds. The DON confirmed staff weighed Resident #1 weekly and noted the decline, and further confirmed the facility's protocol was to refer Resident #1 back for continued RD services. The DON confirmed the facility could have re-instated tube feedings to slow and prevent continued weight loss. The DON stated she notified the physician of Resident #1's weight loss on 07/31/2020. During an interview with RD A on 12/22/2020 at 6:08 p.m., RD A confirmed she emailed staff about her assessment, dated 07/01/2020. RD A stated there was be reason to be concerned that staff did not monitor Resident #1's weights weekly resulting in a weight loss when staff could have implemented interventions per her or physician recommendations. RD A stated re-instating Tube Feedings would have been an option. During an interview with the DON on 12/23/2020 at 9:46 a.m., the DON stated the facility had multiple nurse's assistants and agency staff who did not have access to their computers systems which would explain all of the lack of documentation on Resident #1's daily meal intake record. Record review of the facility's policy, Change in a Resident's Condition, revised 12/2017, revealed: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing payment, resident rights, etc.).