Every finding on record at Eden Home

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 5 residents (Residents #1) reviewed for infection prevention measures. CNA A provided care for Resident #1 who had a need for an indwelling urinary catheter and was under Enhanced Barrier Precautions (EBP, an infection control measure in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at risk of spreading multidrug-resistant organisms) and did not wear any Personal Protection Equipment (PPE). This failure could place residents at risk for infections. Findings included: A record review of Resident #1s admission record, dated 4/30/2026, revealed an admission date of 1/1/2026 with diagnoses including chronic kidney disease (a long-term, progressive condition where kidneys are damaged and cannot effectively filter blood. It is characterized by persistent kidney damage for at least 3 months, often leading to waste buildup) and Urinary tract infections. A record review of Resident #1's admission MDS assessment, dated 1/7/2026 revealed Resident #1 was a [AGE] year-old female admitted for LTC and assessed with a need for an indwelling urinary catheter. A record review of Resident #1's physicians orders, dated 4/30/2026, revealed, upon admission, the physician prescribed for Resident #1 to have an indwelling urinary catheter and for staff to care for the catheter, which included cleansing, draining the collection bag, securing the drainage line. A record review of Resident #1's care plan, dated 4/30/2026, revealed, ADLs (activities of daily life) President has potential for self-care deficit . personal hygiene: requires assistance of one staff. The resident has indwelling catheter. The resident will show no signs or symptoms of urinary infection through the review date July 8th, 2026. During an observation and interview on 4/30/2026 at 3:14 p.m., Resident #1's room had signage posted which stated, STOP - Enhanced Barrier Precautions - EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high contact resident care activities: dressing, bathing showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use; central line, urinary catheter, feeding tube, tracheostomy, wound care; any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. During an observation and interview on 4/30/2026 at 3:15 p.m., revealed Resident #1 in her room in the bathroom seated on the toilet with CNA A waiting for her. CNA A was observed not wearing any PPE. CNA A stated Resident #1 was receiving patient care, was seated on the toilet, and he was awaiting her to complete her bowel movement, and he would assist Resident #1 with cleansing and dressing. During an interview on 4/30/2026 at 3:30 p.m., LVN B stated she was the charge nurse for Resident #1 and CNA A. LVN B stated Resident #1 needed an indwelling urinary catheter and enhanced barrier precautions related to the catheter. LVN B stated her delegation for CNA care for residents with a need for EBP was for CNA's to wear EBP PPE which included hand hygiene, the donning (the practice of applying PPE) of a gown and gloves, provide the care, and upon completion of the care the CNA was expected to doff (the practice of removing PPE) the PPE provide hand hygiene and exit the room. LVN B stated her CNA was CNA A and if he was providing care for Resident #1, CNA A should have donned (the practice of applying PPE) PPE to include gowns and gloves and should have continued with the gown and gloves until the care was completed. LVN B stated the failure to wear PPE for residents who had a need for EBP could be the spread of infections. During an interview on 4/30/2026 at 3:38 p.m., LVN Staff Educator stated she was the facility nurse educator and provided training, which included PPE EBP training, for CNAs. LVN Staff Educator stated Resident #1 needed an indwelling urinary catheter and enhanced barrier precautions related to the catheter. LVN Staff Educator stated her training for CNAs' care for residents with EBP was for CNAs to wear EBP PPE which included hand hygiene, the donning of a gown and gloves, provide the care, and upon completion of the care the CNA was expected to doff the PPE provide hand hygiene and exit the room. LVN Staff Educator stated she trained CNA A when providing care for Resident #1 CNA A should have donned PPE to include gowns and gloves and should have continued with the gown and gloves until the care was completed. LVN Staff Educator stated the failure to wear PPE for residents who had a need for EBP could be the spread of infections. A record review of the facility's Personal Protective Equipment policy, dated 8/29/2019, revealed, The facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Policy explanation and compliance guidelines: all staff who have contact with residents and or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Personal protective equipment will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infectious status. Multiple factors determine the appropriate selection of personal protective equipment for a particular task: the type of exposure anticipated for example splash, spray versus touch. The volume of fluid or tissue to which there is a potential exposure. The likelihood of exposure. The probable route of exposure; for example, direct contact versus inhalation. The need for transmission-based precautions. Indications considerations for personal protective equipment use: gloves, . gowns, . face protection, . respiratory protection, . Sequence of donning removing personal protective equipment when using multiple types: put on personal protective equipment in this order: gown, mask or respirator, goggles or face shield; then gloves.

Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 2 of 2 residents (Resident #91 and Resident #117) and in 1 of 1 oxygen storage rooms reviewed for respiratory care. 1. Resident #91's nasal cannulas for oxygen and BiPAP (bilevel positive airway pressure) mask were not covered in a plastic bag when they were not used on 03/17/2026. 2. The facility failed to ensure Resident #117's oxygen concentrator was set to 2 to 3 liters per minute as ordered by the physician on 03/17/2026 and 03/18/2026. 3. Stored oxygen was not separated -1 oxygen cylinder that was empty was in the full area. 1 oxygen cylinder that was empty was in the full side. This failure could place residents at risk of illness, respiratory complications and accidents. The findings included:3. Observation on 3/18/2026 at 9:19 AM in the oxygen cylinder room, revealed 15 oxygen tanks. There was 1 oxygen cylinder that was empty in the full side and 1 oxygen cylinder that was full on the empty side. Interview on 3/18/2026 at 9:19 AM with RN E confirmed 1 oxygen cylinder that was empty on the full side and 1 oxygen cylinder that was full on the empty side. RN E confirmed all full oxygen cylinders should be on the full side of the room, and all empty cylinders should be on the empty side of the room. Interview on 03/19/2026 at 4:33 PM with the DON stated all the full oxygen cylinders should be in the full side, and the empty cylinders should be in the empty side of the room. DON stated they did not have a policy for the oxygen cylinder room. Interview on 3/20/2026 at 11:11 AM with ADM stated she was not aware the oxygen cylinders were mixed up in the room. Oxygen policy requested from administraor but was not provided prior to exit. Record review of Resident #117's face sheet, dated 03/17/2026, revealed she was admitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of plaque inside the artery walls), and generalized anxiety disorder. Record review of Resident #117's Quarterly MDS assessment, dated 02/03/2026, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. Section O Special Treatments, Procedures, and Programs revealed C1 Oxygen Therapy was coded for Resident #117's oxygen use while a resident. Record review of Resident #117's care plan, initiated date of 01/01/2026, revealed a focus of The resident has oxygen therapy r/t COPD with an intervention of OXYGEN SETTINGS: O2 @ 2-3 LPM VIA NC AS NEEDED FOR O2 SAT 90%. Record review of Resident #117's physician order summary report, dated, 03/17/2026, revealed a physician order reading O2 @ 2-3 LPM VIA NCAS NEEDED FOR O2 @ SAT<90% every 24 hours as needed for SOB with a start date of 07/31/2025. Observation on 03/17/2026 at 11:02 a.m. revealed Resident #117 lying in bed with the head of bed elevate wearing nasal cannula and oxygen concentrator set at 4 liters per minute. Observation and interview on 03/18/2026 at 9:46 a.m. revealed Resident #117 lying in her bed with the head of the bed elevated, wearing her nasal cannula and oxygen concentrator set at 4 liters per minute. Resident #117 stated she had been using oxygen since she was admitted to the facility about a year ago. Resident #117 further stated the oxygen concentrator should have been set at around 2 liters per minute, then asked what it was set at and she stated 4 liters per minute was rather high. During an interview and observation on 03/18/2026 at 9:57 a.m. RN B stated Resident #117's oxygen concentrator should have been set at 2 liters per minute. RN B was observed checking Resident #117's oxygen concentrator and stated oh, no it's set at 4 liters per minute, and adjusted the oxygen concentrator to 2 liters per minute. RN B stated as long as she had been working with Resident #117 the oxygen concentrator had been set at 2 liters per minute. RN B stated that by not having the oxygen concentrator properly set it could affect Resident #117's oxygenation. RN B further stated by the oxygen concentrator having been set at 4 liters per minute it could have caused a buildup of carbon monoxide. RN B was observed reviewing Resident #117's physician orders and RN B stated Resident 117's physician order was for 2 to 3 liters per minute. RN B stated maybe the oxygen concentrator was turned up due to Resident #117 having been declining but she was not sure. During an interview on 03/19/2026 at 4:09 p.m. the DON stated by not following physician's orders or setting a resident's oxygen concentrator too high it could cause a resident to get too much oxygen and their CO2 levels could be too high. The DON further stated this could cause a resident to become confused. The DON stated the nurses were responsible for making sure the oxygen concentrators were set to the right liters per minute. During an interview on 03/20/2026 at 1:47 p.m. the Administrator stated the nurse was responsible for ensuring oxygen concentrators were set at the proper settings. The Administrator further stated if the oxygen concentrator was too high a person with COPD could possibly have damage to their lungs or if too low it could take the O2 (oxygen) SATS (saturations) down. Record review of facility's policy titled Oxygen Therapy,, dated 03/16/2022, read, Policy: To ensure residents who require oxygen receive it safely according to physician guidelines and orders. 1. Record review of Resident #91's face sheet, dated 03/20/2026, revealed the resident was an 89-years-old male and admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy (loss of skeletal muscle mass), acute respiratory failure (when fluid leaks from small blood vessels in the lungs and builds up in the air sacs), and chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems). Record review of Resident #91's admission MDS assessment, dated 01/20/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognition was intact and was receiving oxygen therapy and non-invasive mechanical ventilator (BiPAP - bilevel positive airway pressure). Record review of Resident #91's comprehensive care plan, dated 02/23/2026, revealed the resident had the care plans of [Resident #91] has altered respiratory status/difficulty breathing related to chronic obstructive pulmonary disease. For interventions - BIPAP via full-face mask to be worn at night while sleeping and OXYGEN SETTINGS: O2 (oxygen) via NC (nasal cannula) at 3.5 liter per minute continuously and per physician orders. Record review of Resident #91's physician order, starting dated 01/14/2026, revealed the resident had the orders of Bipap to be worn every night while sleeping every night shift, change nebulizer tubing, ensure it is bagged and dated; wipe/clean nebulizer machine with disinfecting wipe every night shift every Friday, change oxygen concentrator/tank tubing, ensure it is bagged & dated; change humidifier water bottle & date it; check & clean oxygen concentrator filter; ensure sign is in place on door; wipe/clean oxygen concentrator with disinfecting wipe every night shift every Friday, and oxygen at 3.5 liter per minute via nasal cannula continuously every shift. Observation on 03/17/2026 at 10:45 a.m. revealed Resident #91 was not in the room, but there was an oxygen concentrator at the bedside, and the nasal cannula was on the concentrator not covered with a plastic bag. There was also a Bipap machine at the nightstand, and the mask connected to the machine was on the nightstand not covered with a plastic bag. In Resident #91's restroom, another nasal cannula was on the walker not covered with a plastic bag. Interview on 03/17/2026 at 11:38 a.m. with RN-G stated Resident #91's nasal cannulas for oxygen and BiPAP mask were not covered in a plastic bag when they were not used. The nurse said they should have been covered with plastic bags to prevent infection, and it was the facility nurse's responsibility. Interview on 03/19/2026 at 3:45 p.m. with the DON said the facility nurses should have covered Resident #91's nasal cannula and Bipap mask with a plastic bag to prevent infection. Record review of the facility policy, titled oxygen therapy, dated 04/19/2018, revealed . 14. Nasal cannula will be cleaned with cotton tipped applicator and normal saline as needed. Replacement of tubing and humidifier will be done weekly, on Friday and dated. Oxygen masks will be cleaned with normal saline and dried as needed and changed and dated weekly. When not in use, nasal cannula or mask will be stored in Ziplock bag and kept in beside drawer.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 2 medication rooms (500-hall medication room), 2 out of 5 medication carts (500-hall B nursing cart and 500-hall A nursing cart), and 2 of 7 residents (Residents #52 and #155) reviewed for pharmacy services. 1. There was one box of refresh plus eye drop lubricant 50 vials that expired 01/2026 found inside the 500-hall medication room on 03/18/2026. 2. There was one bottle of Mucinex 600 mg guaifenesin extended-release that expired 12/09/2025 found inside the 500-hall B nursing cart on 03/18/2026. 3. There was one insulin lispro injection pen of Resident #52 that was opened on 02/09/2026 found inside the 500-hall A nursing cart on 03/18/2026. 4. MA-I took Resident #55's blood pressure and failed to notify the charge nurse of the low blood pressure prior to administering the blood pressure medication. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Observation on 03/18/2026 at 2:34 p.m. revealed inside the 500-hall medication room, there was one box of refresh plus eye drop lubricant eye drops 50 vials, and they were all expired 01/2026. Interview on 03/18/2026 at 2:34 p.m. with RN-B stated there was one box of refresh plus eye drop lubricant eye drops 50 vials, and they were all expired 01/2026. RN-B said the one box of refresh plus eye drop lubricant eye drops 50 vials should have been discarded, but the nurse did not know what reason the medications were still in the 500-hall medication room, and if a nurse used the expired medications, residents might have dry eyes. 2. Observation on 03/18/2026 at 2:46 p.m. revealed inside the 500-hall B nursing cart, there was one bottle of Mucinex 600 mg guaifenesin extended-release, and the medication expired 12/09/2025. Interview on 03/18/2026 at 2:46 p.m. with RN-B stated inside the 500-hall B nursing cart, there was one bottle of Mucinex 600 mg guaifenesin extended-release, and the medication expired 12/09/2025. RN-B said the one bottle of Mucinex 600 mg guaifenesin extended-release should have been discarded, but the nurse did not know what reason the medications were still in the 500-hall B nursing cart, and if a nurse used the expired medications, residents might have mucus. 3. Record review of Resident #52's face sheet, dated 03/20/2026, revealed the resident was a 78-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of displaced bicondylar fracture of right tibia (right knee fracture), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), and muscle weakness. Record review of Resident #52's quarterly MDS assessment, dated 03/01/2026, revealed the resident's BIMS score was 11 out of 15 which indicated the resident had moderate cognitive impairment and received insulin injections. Record review of Resident #52's physician order, starting dated 11/23/2025, revealed the resident had the order of Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2 Units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401 more Call doctor, subcutaneously before meals and at bedtime for Diabetes. Observation on 03/18/2026 at 2:53 p.m. revealed inside the 500-hall A nursing cart, there was Resident #52's Insulin Lispro Pen Injector, and it was opened on 02/09/2026. Interview on 03/18/2026 at 2:53 p.m. with LVN-J stated there was Resident #52's Insulin Lispro Pen Injector inside the 500-hall A nursing cart, and it was opened on 02/09/2026. The nurse said per the facility policy, they should have discarded Resident #52's insulin Lispro pen 28 days after it was opened, and the date was 03/09/2026. LVN-J said she used a new insulin Lispro pen for the resident on 03/18/2026, but other nurses might use it and the nurse said she did not know what reason the nurses did not discard it on 03/09/2026, and if a nurse used the expired insulin, residents might not have normal blood sugars. 4. Record review of Resident #155's face sheet, dated 03/20/2026, revealed the resident was a 79-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of arthritis (redness and swelling - inflammation of a joint), 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 #155's admission MDS assessment, dated 03/19/2026, revealed the assessment was still in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #155's physician order, starting dated 03/06/2026, revealed the resident had the order of Enalapril Maleate Tablet 20 milligram - Give 1 tablet by mouth two times a day for BLOOD PRESSURE. Further record review of the resident's physician order revealed there was no specific parameter regarding holding the medications for blood pressures. Observation on 03/19/2026 at 8:39 a.m. revealed MA-I took Resident #155's blood pressure before giving the resident's medications, and the blood pressure was 113/54 and pulse 85 per minute. MA-I gave the medication of Enalapril Maleate Tablet 20 milligram 1 tablet to Resident #155, and the resident took it by mouth. Interview on 03/19/2026 at 8:44 a.m. with MA-I said Resident #155 did not have specific parameter regarding holding blood pressure medications, but MA-I said she generally held Resident #155's Enalapril Maleate if the resident's systolic blood pressure (top number) was less than 100 and reported it to the charge nurse. Further interview on 03/19/2026 at 2:09 p.m. with MA-I said she should have reported Resident #155's blood pressure to the charge nurse because the resident's diastolic blood pressure was 54, and it was a little bit low to normal range, and it was her mistake. Interview on 03/19/2026 at 1:55 p.m. with the DON said Resident #155's primary care physician did not give specific blood pressure parameter regarding the resident's Enalapril Maleate because the physician wanted to know the resident's blood pressure whenever the facility nurses notified if the blood pressures were out of normal ranges. The DON said the facility did not have specific policy regarding blood pressure, but the facility medication aides should take blood pressure before giving blood pressure medications, and if the values were out of normal ranges, medication aides should report to the charge nurse, and the charge nurses should retake the blood pressure with a manual blood pressure cuff. The DON stated the normal blood pressure values were between 110/60 to 140/90. The DON said MA-I should have reported Resident #155's blood pressure to the charge nurse before giving the resident's Enalapril Maleate because the resident's blood pressure was 113/54 to prevent possible adverse effects, and Resident #155 did not have any side effects and cardiac issue. Further interview with the DON on 03/19/2026 at 3:45 p.m. said the facility did not have specific policy regarding expired medication, but the facility never used any expired medication. Interview on 03/19/2026 at 2:07 p.m. with RN-K stated MA-I should have reported Resident #155's blood pressure to the charge nurse before giving the resident's Enalapril Maleate because the resident's blood pressure was 113/54 to prevent possible adverse effects, and if MA-I reported to the nurse, the nurse might retake the resident's blood pressure with a manual blood pressure cuff. The nurse said she retook the resident's blood pressure at 2:00 pm with a manual cuff, and it was normal range 120/80. Record review of the facility policy, titled Insulin Discard After Dates, revised 03/29/2021, revealed Humalog vitals and pen (Lispro) - discard date after opening at room temperature 28 days.

Based on observation, interview, and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete for 1 of 6 residents (Resident #105) and the facility failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 4 halls (hall#8000), reviewed for Administration. 1. The facility failed to ensure Resident #105's wound care physician visits and notes were documented in the resident's EHR prior to or after the resident's discharge on [DATE]. 2. The facility failed to ensure the Medical Records room/Staff break room was closed and kept private and secure. These failures could place residents at risk of not receiving appropriate follow up care, decreased continuity of care, and loss or unauthorized use of their medical records.The findings were: 1. Record review of Resident #105's face sheet dated 3/17/26 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #105's diagnoses included fusion of spine cervical region (surgical procedure that permanently connects two or more vertebrae in the neck), central cord syndrome at unspecified level of cervical spine (an incomplete spinal cord injury to the neck), muscle wasting and atrophy not elsewhere classified multiple sites (wasting or loss of muscle tissue), and other abnormalities of gait and mobility (abnormal walking pattern and the ability to move freely, coordination). The resident discharged home with home health on 3/9/26. Record review of Resident #105's admission MDS assessment dated [DATE] indicated the resident had clear speech, was understood by others and had clear comprehension. The resident had a BIMS score of 13 of 15 indicating the resident was cognitively intact The resident was Dependent - helper does all of the effort and the 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 for rolling in bed, lying to sitting, sit to stand, and all transfers. The resident had a urinary catheter, was always incontinent of bowel, was at risk for pressure ulcers/injuries but did not have any currently. The resident also had moisture associated skin damage (MASD). Record review of Resident #105's undated care plan revealed a focus initiated on 1/22/26 for the resident was admitted with an unstageable pressure ulcer to his sacral/buttocks and the potential for pressure ulcer development r/t immobility and refusal of use of pressure relieving devices, resident refuses to lay down during the day because laying down hurts his neck/back injury, refused air mattress due to it being too hard and him not being able to tolerate it even on alternating low pressure settings. And added to this focus dated 2/15/26 for a new unstageable pressure ulcer to the left heel, with interventions that included Assess/record/monitor wound healing weekly measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD. Record review of Resident #105's weekly wound care nurse wound assessments revealed ten total assessments dated 1/19/26, 1/26/26, 2/2/26, 2/10/26, 2/15/26, 2/17/26, and 2 assessments for each wound on 2/23/26 and 3/4/26 were all created and signed on 3/10/26 by LVN C the day after the resident discharged from the facility. Record review of Resident #105's EHR on 3/19/26 at 11:35 a.m. revealed there were no wound care physician progress notes and no documentation the wound care physician had seen the resident. Record review of Resident #105's EHR on 3/20/26 at 11:00 a.m. revealed there was one physician wound care progress note with an effective date of 2/19/26 that was uploaded on 3/20/26 at 10:58 a.m. In a joint interview on 3/19/26 at 12:43 p.m. with LVN C and LVN D. LVN C stated she had been at the facility for 6 years and was taking over the wound care nurse position from LVN D but LVN D was still assisting as LVN C was still training. LVN C stated she did enter the weekly wound care nurse wound assessments on 3/10/26 in the computer but she had them all documented on paper and had put them all in on the same day on 3/10/26 as she was still learning the system. LVN C and LVN D stated Resident #105 was seen by the wound care physician weekly. LVN D stated his progress visit notes may not be uploaded yet and she would check with medical records and would call the physician for his notes. In an interview on 3/20/26 at 10:50 a.m. LVN D stated she did not know if the physician's wound care progress notes should have been in Resident #105's EHR prior to his discharge on [DATE]. In an interview on 3/20/26 at 11:00 a.m. LVN D stated the wound care physician progress notes had been uploaded to Resident #105's EHR under the miscellaneous tab. LVN D stated the progress note dated 2/19/26 was the only note as that was the only time he saw the resident as the resident was in the hospital one week and the wound care physician did not come another week. In an interview on 3/20/26 at 12:00 p.m. the DON stated it depended on if the physician had sent the facility his progress notes or not as to whether the wound care notes should have been in Resident #105's EHR from 2/19/26 to his discharge on [DATE] or prior to today. The DON was non-responsive when asked to elaborate. The DON stated there were no possible consequences to the resident for his wound care progress notes not being entered in the resident's medical record. Review of the facility policy on medical records dated 11/2/2020 indicated This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice. 1. A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident. Electronic clinical records will contain at least but are not limited to .c. Physician documentation. Observation on 3/18/2026 at 9:19 AM on the Bluebonnet hall (8000) revealed the staff break room was open, had a microwave, a bathroom, a spa, and had personal resident records on a shelf. The resident charts had their face sheet, orders, miscellaneous records and the hospice resident charts were kept in the room. Interview on 3/18/2026 at 9:20 AM RN E stated this room had always been a break room with residents' personal charts on a shelf. Observation on 3/19/2026 at 10:16 AM revealed the staff break room was open and had resident personal records in the room. (same staff room as above). Interview on 3/19/2026 at 10:19 AM with LVN F stated the open door was a staff break room, had a bathroom, a spa, a microwave and where they kept the resident personal charts. LVN F stated not everyone has access to charts. Interview on 3/19/2026 at 4:33 PM the DON stated she did not see an issue with the staff/personal charts room and the door being opened. The DON stated she could guarantee the residents/family could not go into the staff/personal resident chart room. The DON stated there was minimal information in the resident charts. Interview on 3/20/2026 at 11:11 AM with ADM stated she was not aware the staff/resident chart room was open and the charts contained vital information of residents. Review of the facility policy on medical records dated 11/2/2020 indicated This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice. 6. Caution should be used when sharing confidential medical information about residents with employees or other providers from the clinical record. 8. Unauthorized personnel are permitted to review records only with the signed permission of the resident or a legal document allowing such access.

Based on observation, interview and record review the facility failed store food in accordance with professional standards for food service safety. for 1 of 3 (Bluebonnet Hall unit pantry) unit pantries in that:The unit pantry refrigerator was out of range temperature; and the apple juice container was not labeled or dated.This could affect residents that used the unit pantry and place residents at risk for food borne illnesses. The Findings:Observation on 3/18/2026 at 9:13 AM in the Bluebonnet Hall unit pantry revealed the refrigerator temperature was at 42 degrees Fahrenheit. The apple juice container was half full and was not dated or labeled.Observation on 3/18/2026 at 10:18 AM in the Bluebonnet Hall unit pantry revealed the refrigerator temperature was 42 degrees Fahrenheit. The apple juice container was half full and was not dated or labeled.Interview on 3/18/2026 at 10:22 AM with RN E confirmed the Bluebonnet Hall unit pantry refrigerator was at a temperature of 45 Degrees Fahrenheit. RN E stated if refrigerator unit was higher than 42 degrees Fahrenheit, it could cause food to spoil. RN E confirmed the apple juice had no label and was not dated. RN E stated this could cause spoilage and was not sure why it was not labeled. The unit refrigerator was used for residents when they needed snacks or hydration. The Temperature was checked daily. The staff using the food item was responsible for labeling and dating open containers. Interview on 3/19/2026 at 4:33 PM with the DON stated she was not sure why the Bluebonnet Hall unit pantry refrigerator temperature was high and stated maybe residents/staff had just opened it.Review of FDA Food Code states for safety, it is important to verify the temperature of the refrigerator. Refrigerators should be set to maintain a temperature of 40 F or below. Record review of Resident Food Services, unit pantry stock, dated 5/95 reflected Policies: Food and Nutrition Services stocks unit pantries with snacks that are available for general resident use and with foods for residents who eat meals at non- traditional mealtimes. All open items must be labeled open and use-by-date. Procedures: Label, date and discard outdated items per food storage policy. Nursing and/or Food and Nutrition Services Designee: The Temperature of the refrigerator and freezer will record at least once daily. Temperature variance out of the acceptable range will be reported.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #117) who were observed for call light placement. The facility failed to ensure the call light which had been placed on Resident #117's oxygen concentrator was within reach for Resident #117. This deficient practice could place residents at risk of not being able to call for help as needed.The findings included: Record review of Resident #117's face sheet, dated 03/17/2026, revealed she was admitted to the facility on [DATE] with diagnoses which included: carcinoma (cancer) in situation of anus and anal canal, generalized anxiety disorder, muscle wasting and atrophy, not elsewhere classified, multiple sites, unsteadiness on feet, other abnormalities of gait and mobility, need for assistance with personal care, and history of falling.Record review of Resident #117's Quarterly MDS assessment, dated 02/03/2026, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. The Quarterly MDS assessment further revealed Resident #117 required partial/moderate assistance (helper does less than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity) for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer.Record review of Resident #117's care plan, initiated date of 08/01/2025, revealed a focus of Fall Risk: Resident is at risk for fall due to disease process with an intervention of Keep call light within easy reach, teach and encourage to use it.Observation and Interview on 03/17/2026 at 11:02 a.m. revealed Resident #117 was observed lying in bed with the head of bed elevated, her covers over her legs and call light hanging through the handle of the oxygen concentrator at the left side of the head of her bed. Resident #117 stated she did use her button when she needed help and felt with her hand the quarter bed rail near the head of the bed and could not locate it. When Resident #117 stated she could not feel it with her hand she stated, I do not know where it is, they usually put it here.Observation on 03/17/2026 at 11:52 a.m. revealed Resident #117's call light remained hanging from her oxygen concentrator through the handle of the oxygen concentrator where she could not reach it. During interview and observation on 03/17/2026 at 12:11 p.m. CNA A stated Resident #117 typically used her call light and Resident #117 had a shower that morning and the hospice helped her back in bed. CNA A further stated Resident #117 had woken up confused that morning and Resident would use her call light sometimes. CNA A stated Resident #117 would not have been able to reach it where it was located and then CNA A wrapped the call light around the quarter rail at the head of the bed within reach of Resident #117. CNA A stated they would usually wrap Resident #117's call light to the side rail so it was close. CNA A stated residents used the call light for getting help and if they needed assistance, to go to the restroom, if they wanted water or anything. CNA A stated by residents not having the call light the staff would not be aware of when a resident needed something.During an interview on 03/19/2026 at 4:02 p.m. the DON stated it was everyone's responsibility, including the hospice who was in there earlier to ensure residents have their call lights. The DON could not answer when staff would go into check on residents after hospice had provided care. The DON stated residents used the call lights to contact staff. During an interview on 03/20/2026 at 1:51 p.m. the Administrator stated everyone was responsible for ensuring call lights were in place. The Administrator stated by Resident #117 not having the call light within reach she could try to get up herself and fall or not be able to call for help. The Administrator stated call lights were used to notify staff when someone needed help or assistance. Record review of facility's Fall Prevention policy, dated 09/16/2020, read Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 5. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: iii. Call light and frequently used items are within reach.

Based on observations, interviews and record review the facility failed to ensure the resident had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, including the right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 of 8 (Resident #136) residents in that:Resident #136 was not able to eat in her room, which was her preference.This failure could affects the residents' ability to live a dignified life at facility.The findings: .Record review of Resident #136's admission Record dated 3/18/2026 reflected that she was admitted on [DATE], re-admitted on [DATE] with diagnoses of multiple sclerosis (is a chronic autoimmune disease in which the immune system attacks the protective myelin sheath surrounding nerve fibers in the brain and spinal cord, disrupting communication between the brain and the rest of the body), dysarthria following other cerebrovascular disease (motor speech disorder caused by neurological injury, which affects the muscles used for speaking) , anxiety, quadriplegia (symptom of paralysis that affects all a person's limbs and body from the neck down), cognitive communication deficit (condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes, rather than a primary problem with language or speech.), need assistance with personal care, dependence on wheelchair, contracture) (affect your skin, muscles, joints, tendons or other soft tissues. It happens when scarring or fibrosis makes the tissues tighten and stiffen. Without swift intervention, contracture can permanently reduce your range of motion) to right elbow, right hand and left hand.Record review of Resident #136's Quarterly MDS dated [DATE] revealed she had a BIMS of 15/15 (cognitively intact), she used an electric wheelchair, she was dependent on staff for all ADLs, she was always incontinent, she had quadriplegia, multiple sclerosis, anxiety, multiple contractures, and speech disturbances.Record review of Resident #136's care plan dated 12/2/2025 revealed she had Multiple sclerosis, hand contractures, she required assistance for all ADLs, at risk for impaired social interaction related to limited mobility, and dependent on staff for meeting emotional, intellectual, physical, and social needs related to depression and MS.Record review of Grievance for Resident #136, dated 1/12/2026, written by the SW stated Residents, [family member] reported that resident was brought to the dining area, approximately 1.5 hours prior to lunch with her bib already in place. {Resident #136's} family stated {Resident #136} informed staff that she did not wish to eat in the dining room: however, she was informed that due to the number of residents requiring assistance with feeding, this would not be possible. The resident stated that she felt embarrassed sitting in the dining area with her bib on for an extended period of time and reported that she had to stare at a wall for approximately 1.5 hours before the meal was served, as there was no TV available for her to watch. Signed and dated 1/13/2026 by SW and ADM. SW informed the ADM on 1/13/2026.Record Review of progress note by RN E dated 1/11/2026 at 2:20 PM, reflectedPatient upset that staff brought her out to dining room for lunch to be fed. Not enough staff on floor to feed everyone in room. Explained to patient the situation. She remained unagreeable. Notified DON of situation and she agreed with bringing patient to dining room. Patient was fed lunch and taken back to room once completed. Observation on 3/17/2026 at 11:58 AM with Resident #136 revealed she required a computer to assist her with communicating and could speak out in phrases but was difficult to understand. Resident #136 was in her electric wheelchair and was moving eyes to type out words and phrases on her computer laptop. Observation on 3/20/2026 at 1:50 PM with Resident #136, revealed was being feed by CNA in her room. Interview on 3/19/2026 at 4:33 PM with the DON stated LVN E did notify her about Resident #136, not wanting to eat in the dining room. DON stated she felt it was safer for Resident #136 to eat in the dining room. DON stated it takes staff an hour to feed Resident #136. Interview on 3/20/2026 at 10:30 AM with SW stated Resident #136's family member, had come in and reported Resident #136 had texted her the above grievance. SW stated Resident #136 required assistance with feeding with 1 staff, and that day she was asked to get out of her room to go to the dining room. SW stated Resident #136 does not like coming out of her room. SW stated Resident #136's BIMs level is 15/15, she likes to be in her room, so she could communicate with laptop computer device, and took her time to focus, she was able to type out phrases with her eyes. Interview on 3/20/2026 at 11:28 am with MDS nurse, stated Resident #136 preferred to be in her room, she used the computer to communicate with staff. MDS nurse stated she was not aware of the situation Interview on 03/20/2026 at 2:00 PM with RN E stated they did not have enough staff to feed Resident #136 in her room. RN E called DON and explained situation (Resident #136 wanted to eat in her room, and not enough staff to feed Resident #136 in her room). RN E stated that it would be better if Resident #136 ate in the dining room. RN E stated Resident #136 did not have to wait. RN E stated Resident #136 was ok eating in the dining room. Interview on 3/20/2026 at 11:11 AM with ADM stated she did get the grievance report for Resident #136 , and would have to research it more. ADM stated this incident with Resident #136 was a grievance and not reportable to the state. ADM stated it was Resident #136's preference to stay in her room, she has her computer to communicate with staff/visitors. Record review of policy, Resident Rights, (no date) reflected Residents of Texas nursing facility have all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of the state and United States. They have the right to be free of interference, coercion, discrimination and reprisal in exercising these rights as citizens of the United States. Dignity and Respect, you have the right to be treated with dignity, courtesy, consideration and respect. Freedom of Choice, you have a right to make your own choices regarding personal affairs, care, benefits and services.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #156) out of 26 residents reviewed for environmental concerns. Resident #156's toilet seat was dirty with feces, and staff did not flush feces inside the toilet. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.The findings were: Record review of Resident #156's face sheet, dated 03/20/2026, revealed the resident was an 88-years-old female and admitted to the facility on [DATE] with the diagnoses of muscle weakness, Parkinson's disease (progressive movement disorder of nervous system), and depression (lowering of a person's mood). Record review of Resident #156's admission MDS assessment, dated on 03/20/2026, revealed the MDS assessment was still in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #156's baseline care plan, dated 03/12/2026, revealed the resident had the care plan of Resident has potential for self-care deficit due to impaired mobility and weakness. For intervention - TOILETING: Requires assistance of one staff. Observation on 03/17/2026 at 10:40 a.m. revealed Resident #156 was on the wheelchair and watching TV in her room. The room had a bathroom, and on the toilet seat, there were brown color particles, and it looked like human feces. Further observation revealed inside the toilet, there was a lump of feces. Interview on 03/17/2026 at 10:42 a.m. with Resident #156 stated Resident #156 could not use her bathroom by herself, and staff should help Resident #156 to use the bathroom. Resident #156 said every staff was very nice and helped Resident #156 whenever Resident #156 required and did not know if or not staff cleaned the bathroom. Interview on 03/17/2026 at 11:34 a.m. with RN-G stated there were brown color particles on the toilet seat and it was feces, and there was a lump of feces inside the toilet in Resident #156's bathroom. RN-G said staff did not clean the toilet seat and did not flush the toilet because Resident #156 could not use the bathroom by herself, and staff should put the resident on the toilet seat, clean the resident when the resident finished bowel movements on the toilet, and flush the toilet because the resident could not flush toilet by herself. RN-G said she did not know what reason the staff did not clean and did not flush the toilet, and a dirty bathroom might cause diminished quality of life to the resident. Interview on 03/19/2026 at 3:59 p.m. with DON said staff should have cleaned the toilet seat and should have flushed Resident #156's toilet after helping the resident's bowel movement, and the resident had the right to have a clean and sanitary environment. Record review of the facility policy, titled Resident's Right, dated 11/2021, revealed Dignity and Respect - you have the right to live in safe, decent and clean conditions.

Based on interviews and record reviews the facility failed to ensure the assessment accurately reflected the residents' status for 1 of 8 (Resident #94) residents in that:Resident #94's MDS was not accurate and did not reflect her indwelling catheter.This failure could affect all residents and staff could not know how to provide care to residents.Findings:Record review of Resident #94's admission Record dated 3/20/2026 revealed she was admitted on [DATE] with neuromuscular dysfunction of bladder (refers to what happens when an injury or disease interrupts the electrical signals between your nervous system and bladder function). Record review of Resident #94's consolidated orders for March 2026 revealed she had an order for indwelling foley catheter 16 French (tubing size) for diagnosis of urine retention every shift. May use leg bag while up during day.Record review of Resident #94's Quarterly MDS dated [DATE] revealed she was not marked for have an indwelling catheter.Record review of Resident #94's care plan dated 3/9/2026 revealed she had an indwelling catheter for neurogenic bladder (refers to what happens when an injury or disease interrupts the electrical signals between your nervous system and bladder function).Interview on 3/18/2026 at 10:31 AM with Resident #94 stated she had a leg catheter on at this time.Interview on 3/19/2026 at 11:24 AM with MDS stated it was human error regarding Resident #94's indwelling catheter not being on the MDS. MDS stated they needed to ensure staff are coding correctly and ensure staff are aware of resident care. MDS nurse was responsible for ensuring resident care plan was correct. Interview on 3/19/2026 at 4:33 PM with DON stated the MDS staff had told her she did not code indwelling catheter for Resident #94. DON had no comment.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #64) of 5 residents reviewed for incontinence care. When CNA-A was providing incontinent and indwelling urinary catheter care to Resident #64 on 03/19/2026, the CNA did not clean the resident's left buttock area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #64's face sheet, dated 03/20/2026, revealed the resident was a 91-years-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of spondylosis (the natural progression of degenerative changes in the spine that occur with aging), weakness, and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Record review of Resident #64's Medicare 5 days MDS assessment, dated 12/15/2025, revealed the resident's BIMS score was 12 out of 15 which indicated the resident had moderate cognitive impairment and had urinary indwelling catheter and was always bowel incontinent. Record review of Resident #64's comprehensive care plan, dated 12/11/2025, revealed the resident had the care plan of The resident has Indwelling Catheter. For intervention - Monitor for signs and symptoms of discomfort on urination and frequency. Observation on 03/19/2026 at 10:41 a.m. revealed CNA-A opened Resident #64's old and dirty brief, cleaned the indwelling urinary catheter, genital area, and groin areas, then turned the resident to right side and cleaned the resident's rectum and right buttock area because the resident had bowel movement. Further observation revealed CNA-A changed her gloves and turned the resident to supine position (lying horizontally with the face and torso facing up), put new and clean brief under the resident, and closed the new and clean brief without cleaning the resident's left buttock area. Interview on 03/19/2026 at 11:09 a.m. with CNA-A stated she was nervous and forgot to clean Resident #64's left buttock area. CNA-A said she should have cleaned Resident #64's left buttock area because the resident had bowel movement and to prevent possible infection and skin breakdown. Interview on 03/19/2026 at 3:45 p.m. with the DON said CNA-A should have cleaned Resident #64's left buttock area to prevent possible infection and skin breakdown, and the DON had responsibility to ensure proper care was provided. Record review of the facility policy, titled Perineal Care Procedure, dated 03/15/2019, revealed . 8. If perineum is grossly soiled, turn resident on side, remove any fecal material and discard. A. Cleanse buttocks and anus, front to back, scrotum to anus in males, using a separate washcloth or wipes. B. Thoroughly dry.

Based on interview and record review, the facility failed to ensure abuse, neglect and exploitation training and dementia training for 1 of 5 (CNA-M) employees reviewed for training requirements were completed. The facility failed to ensure abuse, neglect and exploitation training was provided to CNA-M. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA-M revealed a hire date of 11/24/2024. Review of training log provided by human resources revealed no evidence that CNA-M received abuse, neglect and exploitation training. Interview with the Staffing Coordinator on 03/20/2026 at 12:04 PM revealed CNA-M was agency staff and not working at the facility anymore since on 01/19/2026, but the facility should have checked if CNA-M completed abuse, neglect and exploitation training or not before the CNA worked on the floor, and if the CNA did not take the training, the facility should have provided the training to the CNA. The Staffing Coordinator said it was her responsibility if agency staff completed all required trainings, and the Staffing Coordinator did not check if CNA-M completed abuse, neglect and exploitation training or not before the CNA worked on the floor, and it was her mistake. The Staffing Coordinator stated it could lead to mistreatment or neglect of the residents. Record review of the facility policy, titled Abuse prevention, dated 03/16/2022, revealed II. Employee Training. A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 26 residents (Resident #47 and #153) reviewed for infection control practices. 1. RN-G did not put on gloves and a gown when entering Resident #47's room, and Resident #47 was on contact precautions. 2. When LVN-L changed the dressing of Resident #153's gastrostomy tube site, the LVN-L changed her gloves without sanitizing or washing her hands. The deficient practices could place residents at risk for cross contamination and infections.The findings included: 1. Record review of Resident #47's face sheet, dated 03/20/2026, revealed the resident was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of periprosthetic fracture around internal prosthetic right hip joint (fracture associated with an orthopedic implant, whether a replacement or internal fixation device), methicillin resistant staphylococcus aureus infection (caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections), and ESBL (extended spectrum beta-lactamase) in the urine (ESBL producing bacteria cannot be killed by many of the antibiotic that doctors use to treat infections). Record review of Resident #47's admission MDS assessment, dated 02/07/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact and had multidrug-resistant organism as active diagnoses. Record review of Resident #47's comprehensive care plan, dated 02/02/2026, revealed the resident had the care plan of [Resident #47] has admitted with an infection of MRSA (methicillin resistant staphylococcus aureus) in her surgical wound. Re-cultured on 02/09/2026 by wound care and no longer MRSA positive, culture grew e-coli and proteus mirabilis. For intervention - Maintain CONTACT precautions when providing resident care. Record review of Resident #47's physician's order, starting dated 02/24/2026, the resident had the order of CONTACT ISOLATION PRECAUTIONS FOR ESBL (extended spectrum beta-lactamase) IN THE URINE every shift. Observation on 03/17/2026 at 3:35 p.m. revealed RN-G entered Resident #47's room without putting on gloves and a gown and came out from the room with a lunch tray. RN-G then washed her hands with water. Further observation revealed there was a sign on the door, and the sign reflected, Contact Precaution - wearing gown and gloves before entering the room. Interview on 03/17/2026 at 3:37 p.m. RN-G stated she did not wear gloves and a gown when entering Resident #47's room because she forgot. RN-G said she should have put on a gown and gloves before entering the resident's room to prevent infection, and the resident was on contact precautions. Interview on 03/19/2026 at 3:45 p.m. the DON said RN-G should have put on gown and gloves before entering Resident #47's room to prevent infection, and the resident was on contact precautions. 2. Record review of Resident #153's face sheet, dated 03/20/2026, revealed the resident was a [AGE] year-old male and admitted to the facility on [DATE] with diagnosis of adjustment disorder with depressed mood (feeling of sadness, hopelessness, crying and lack of joy from things that used to bring you pleasure), bacteremia (viable bacteria in the blood), and gastrostomy (surgical procedure used to insert a tube, often referred to as G-tube, through the abdomen and into the stomach). Record review of Resident #153's admission MDS assessment, dated 03/19/2026, revealed the assessment was still in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #153's physician's order, starting dated 03/19/2026, revealed the resident had the order of administer jevity 1.2 calories liquid at 75 milliliters per hour Via gastrostomy-tube for 21 hours with 155 milliliters of water. Flush every 6 hours, off at 9 am and Back on at 12 noon for 3 hour downtime To provide calories and CLEANSE Gastrostomy-TUBE SITE WITH WOUND CLEANSER, PAT DRY, AND APPLY SPLIT SPONGE DRESSING every night shift.' Observation on 03/19/2026 at 8:49 p.m. revealed LVN-L completed administering medications via gastrostomy tube to Resident #153 and changed her gloves without sanitizing or washing hands. Further observations revealed LVN-L cleaned Resident #153's gastrostomy tube site, changed her gloves without sanitizing or washing hands, and put a new dressing on the site. Interview on 03/19/2026 at 9:05 p.m. with LVN-L said she changed her gloves without sanitizing or washing her hands because she was nervous and forgot. The nurse said she should have sanitized or washed her hands before wearing new gloves to prevent infection. Interview on 03/19/2026 at 3:45 p.m. the DON said LVN-L should have sanitized or washed her hands before wearing new gloves to prevent infection. Record review of the facility policy, titled Nursing-infection control, dated 08/29/2019, revealed . 4. Indications/consideration for PPE (personal protective equipment) use: a. Gloves - perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly, for 1 of 1 dumpster in that:The garbage container did not have a plug at the bottom.This could affect all residents and could cause debris, foul odors and harborage and feeding of pests.Findings include:Observation on 3/17/2026 at 9:45 AM with FSM, observed the dumpster did not have a plug at the bottom.Interview on 3/17/2026 at 9:45 AM with FSM stated he was not aware that the dumpster did not have a plug and will call the city.Record review of policy, Sanitation and infection preventions, solid Waste disposal dated 5/95, reflected, Policies, Food waste and rubbish in the Food and Nutrition Services Department will be disposed of in an approved manner to prevent contamination of food, clean dishes, or clean working areas.

Based on observation, interview and record review, the facility failed within 14 days after a facility completes a resident's assessment to transmit encoded, accurate, and complete MDS data to the CMS System for 5 of 14 residents (Residents #62, # 86, #107, #123, and #132) reviewed for MDS transmission. 1. Residents #62, #107, #123, and #132's, discharge MDS assessments were not transmitted within 14 days of completion. 2. Resident #86's admission MDS assessment on 03/20/2026 was not completed and not transmitted within 14 days since the resident was admitted to the facility on [DATE]. This deficient practice placed residents at risk of not having completed assessments and not having appropriate care. The findings were: 1. Review of Resident #62's face sheet, dated 03/19/2026, revealed an admission date of 11/05/2025 with diagnoses which included: fracture of unspecified part of right clavicle (a long, slightly curved bone that connects your arm to your body), subsequent encounter for fracture with routine healing, acute and chronic respiratory failure with hypoxia(low levels of oxygen in your body tissues) metabolic encephalopathy (a problem in the brain), muscle wasting and atrophy (waste away), not elsewhere classified, multiple sites, other abnormalities, of gait and mobility, dehydration, unspecified protein-calorie malnutrition, and decreased white blood cell count unspecified. Review of Resident #62's Discharge MDS Assessment, dated 11/17/2025, revealed the assessment had not been transmitted to CMS. Review of Resident #107's face sheet, dated 03/19/2026, revealed an admission date of 11/12/2025 with diagnoses which included: urinary tract infection, site not specified, muscle wasting and atrophy, not elsewhere classified, multiple sites, other abnormalities of gait and mobility, muscle weakness, unsteadiness on feet, chronic diastolic (congestive) heart failure, sleep apnea, unspecified, overactive bladder, hypertension (high blood pressure), and other specified disorders of bone density and structure. Review of Resident #107's Discharge MDS Assessment, dated 11/20/2025, revealed the assessment had not been transmitted to CMS. During an interview and observation on 03/19/2026 at 1:14 p.m. the MDS Coordinator LVN D stated she did not know why Resident #62 and Resident #107's Discharge MDS Assessments had not been transmitted. The MDS Coordinator LVN D reviewed the MDS assessments and they revealed they were locked. The MDS Coordinator LVN D stated they had been locked when the 5-day MDS Assessments were completed due to residents being managed care and would not have transmitted the 5-day MDS Assessments. Review of Resident #123's face sheet, dated 03/19/2026, revealed an original admission date of 10/24/2025 with diagnoses which included: sepsis (life-threatening reaction to an infection) unspecified organism, hypothyroidism(when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs) , unspecified, pure hypercholesterolemia (high cholesterol), unspecified, insomnia unspecified, interstitial pulmonary disease (inflammation and scarring that make it hard for the lungs to get enough oxygen) , unspecified, acute respiratory failure with hypoxia, pain in right shoulder, age-related osteoporosis (disease in which your bones become weak) without current pathological fracture, and age-related physical debility (physical weakness). Review of Resident #123's Discharge MDS Assessment, dated 01/21/2026, revealed the assessment had not been transmitted to CMS. Review of Resident #132's face sheet, dated 03/19/2026, revealed an admission date of 07/05/2025 with diagnoses which included: multiple fractures of pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing, other specified fracture of left pubis, subsequent encounter for fracture with routine healing, muscle wasting, and atrophy, not elsewhere classified, multiple sites, other abnormalities of gait and mobility, muscle weakness (generalized), type 2 diabetes mellitus without complications, generalized anxiety disorder and Alzheimer's Disease with late onset. Review of Resident #132's Discharge MDS Assessment, dated 01/06/2026, revealed the assessment had not been transmitted to CMS. During an interview on 03/19/2026 at 1:30 p.m. the MDS Coordinator LVN H stated she was catching up on other MDS assessments and had not completed the Resident #123's and Resident #132's Discharge assessments. The MDS Coordinator LVN H stated Discharge MDS assessments were for CMS compliance and for tracking/trending of residents going to other facilities. During an interview on 03/19/2026 at 4:05 p.m. the DON stated the MDS Coordinators were responsible for completing the MDS Assessments. The DON further stated they had been down one MDS Coordinator for a long time. The DON stated Medical Records was responsible for transmitting the MDS assessment. The DON stated compliance with CMS could be an issue by not transmitting a MDS assessment, but it was not a care issue. The DON stated by not transmitting MDS assessments it could affect the facility getting paid. During an interview on 03/19/2026 at 4:22 p.m. the RCM (Medical Records) stated she would transmit every day and checked every morning to see if their assessments were ready. The RCM stated she would go into the MDS dashboard and check which were export ready. The RCM stated when the RN had signed off on the MDS assessments she was able to see at that point and she was able to export them to SIMPLE (MDS clearing house that transmits the MDS Assessments and its interfaces with CMS). During an interview on 03/20/2026 at 1:30 p.m. the Administrator stated the MDS coordinators were responsible for the MDS assessments completing and transmitting. The Administrator stated the DON would sign off on the MDS Assessments for completion and then it was sent through SIMPLE LTC which was a portal they use. The Administrator further stated the RCM did the billing and would ensure MDS assessments were transmitted for the billing. The DON stated the MDS assessments were used to generate the care and the Discharge MDS assessments were used to ensure it was a safe and complete discharge. The Administrator stated that by not completing these MDS assessments the facility would not get paid and they would not fully address the individual's needs. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2025 revealed in part, Chapter 5: Submission and Correction of the MDS Assessments 5.2 Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their Stated-specific instrument.Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements.-Assessment Transmission: Comprehensive assessment must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. 2. Record review of Resident #86's face sheet, dated 03/20/2026, revealed the resident was an 85-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of senile degeneration of brain (a range of neurological disorders characterized by a progressive decline in cognition function, impacting memory, reasoning, and the ability to perform everyday activities), dementia (loss of memory and thinking ability), 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 #86's admission MDS assessment, dated 02/10/2026, revealed the MDS assessment was still in progress on 03/20/2026. Interview on 03/20/2026 at 11:23 a.m. with MDS nurse LVN-H said she did not complete Resident #86's admission MDS assessment because she was very busy due to her workload. The MDS nurse stated she should have completed the resident's MDS assessment and transmitted to CMS at least by 02/18/2026 because the resident was admitted to the facility on [DATE], and it was the MDS nurse's responsibility. The MDS nurse said late completion and transmission might affect billing process and the resident might have lack of care because of late comprehensive care plans. Interview on 03/20/2026 at 3:00 p.m. with the DON stated the MDS nurse LVN-H should have completed Resident #86's MDS assessment and transmitted to CMS at least by 02/18/2026 because the resident was admitted to the facility on [DATE], it was the MDS nurse's responsibility, and the DON said she did not know what reason this MDS assessment was late, and it might affect care to the resident. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2025 revealed in part, Chapter 5: Submission and Correction of the MDS Assessments 5.2 Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their Stated-specific instrument.Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements.-Assessment Transmission: Comprehensive assessment must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date.

Based on interview and record review, the facility failed to immediately consult the resident's Physician and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status or an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's Physician and notify the resident's Responsible Party of a worsened wound to sacrum. This failure could place residents at risk of delays in decision making, and poor quality of care and life. Findings Include:Record review of Resident #1's face sheet revealed an [AGE] year old male admitted for respite on 12/01/2025. At the time of admission resident had active diagnosis of sequelae of cerebral infarction (commonly known as a stroke), cerebrovascular disease (condition that affects blood flow to the brain), and hemiplegia, unspecified affecting right dominant side (condition characterized by paralysis on one side of the body). Resident #1 was receiving hospice care at the time of admission. Record review of Resident #1's admission skin assessment, dated 12/01/2025, revealed in section AS_2 nonblanchable (area of skin remains red and does not turn white when pressed) redness to the coccyx (commonly known as the tailbone) was identified. Record review of Resident #1's progress note dated 12/08/2025 revealed LVN A documented Skin Issues : Skin Issue: #001: Skin issue has been evaluated. Location: Coccyx. Additional location information: . Issue type: Other skin issue. Other skin issue description: nonblanchable redness Progress: Deteriorating: wound characteristics deteriorated. Wound was present on admission. It is unknown how long the wound has been present. Length (cm): 2.5 Width (cm): 2.5 Depth (cm): 0 Undermining: No. Tunneling: No. Skin Issues Note: cna notified me that reddened area had opened up. triad applied. Skin issue education: Moisture barrier. Interview with CNA B on 12/11/2025 at 2:08 PM revealed Resident #1 was at the facility for respite. CNA B stated Resident #1 had a small red spot on his butt that looked to be a healing sore when he was admitted . CNA B stated the sore was not open or bleeding. Interview with CNA C on 12/11/2025 at 2:32 PM revealed she had worked with Resident #1 a few days and Resident #1 had a light red spot on his coccyx. CNA C stated while she provided care to Resident #1 on 12/08/2025 at the end of her overnight shift she noticed the skin on Resident #1's sore was redder and appeared to be open. CNA C stated she reported the sore to LVN A who cleaned and applied a cream to the sore. CNA C stated LVN A said he would document the sore and make the notifications. Attempted phone interview with LVN A on 12/11/2025 at 3:09 PM. Surveyor left a message for LVN A requesting a call back. No return call was received. Interview with LVN D on 12/11/2025 at 3:45 PM revealed LVN A had informed her Resident #1 had a new/worsened sore on his coccyx as of late in the overnight shift on 12/08/2025. LVN D stated she agreed to make the notifications to Resident #1's responsible party and physician. LVN D stated she did not make the notifications. LVN D stated it is the responsibility of the charge nurse to make the notifications to ensure residents get appropriate care/treatment. Interview with DON on 12/11/2025 at 3:55 PM revealed LVN A made note that Resident #1 had a worsened wound to the coccyx on 12/08/2025. DON stated the charge nurse was responsible for making notifications to responsible parties and physicians. DON stated it was important to make notifications to ensure the residents were getting the appropriate treatment. Interview with Resident #1's Responsible Party (RP) on 12/12/2025 at 9:00 AM revealed resident was at the facility for 9 day for a respite stay. RP stated Resident #1 did not have any skin integrity issues prior to his stay. RP stated she provided care to Resident #1 upon his return home and found the sore on his coccyx. RP stated she was not notified that the resident had a sore or how to care for the sore. Attempted phone interview with LVN A on 12/12/2025 at 9:25 AM. Surveyor left a message for LVN A requesting a call back. No return call was received. Interview with Nurse Practitioner on 12/12/2025 at 11:08 AM revealed that the facility was to notify the resident's doctor when finding a new or worsened wound. Nurse Practitioner stated the doctor and/or nurse practitioner were not notified of Resident #1's wound. Record review of facility policy named Nursing-Wound Care, dated 04/17/19 revealed c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and upon any newly identified skin issues. Licensed nurse will notify the attending physician/provider and wound care coordinator,. obtain orders, notify POA or Responsible party of wound/treatment, and then document all communication, orders and findings in the medical record. Attempted phone interview with LVN A on 12/12/2025 at 9:25 AM. Surveyor left a message for LVN A requesting a call back. No return call was received.

Based on observations, interviews, and record reviews, the facility failed to ensure resident environments remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one resident (Resident #1) of 3 residents reviewed for 2-person mechanical lift transfers. The facility failed to ensure CNA A transferred Resident #1 on 01/19/2025 with a mechanical lift per her [NAME] (Notes for CNAs to access in PCC to provide a quick overview of the resident's needs) and her comprehensive plan of care plan. CNA A transferred Resident #1 with a gait belt by herself which resulted in a displaced fracture of her right humeral neck (bone at top of arm that connects to ligament (tough fibrous connective tissue) of shoulder). An Immediate Jeopardy was identified as past noncompliance on 5/21/2025. The IJ began on 1/19/25 and ended on 1/20/25. The facility had corrected the noncompliance before the survey began. This failure could put residents at risk of accidents, and could result in serious injury, harm, impairment, and death. The findings included: Record review of Resident #1's face sheet dated 5/20/25 revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] with readmission on [DATE]. The resident's diagnoses included senile degeneration of brain (mental deterioration associated with old age), dementia (a syndrome characterized by a decline in cognitive abilities, affecting memory, thinking, behavior, and the ability to perform everyday activities), chronic kidney disease (long-term condition characterized by the gradual loss of kidney function and leads to the body's inability to filter waste, toxins and excess water from the blood), displaced fracture of surgical neck of right humerus (bone fractures moved around during the fracture causing a gap around the fracture at the top of the right arm near the shoulder), muscle weakness (condition where muscles do not generate enough strength for normal activities), cognitive communication deficit (refers to communication difficulties that arise from cognitive impairments rather than primary language or speech issues) and other abnormalities of gait and mobility (unusual walking patterns or deviations from normal walking, affecting balance, coordination, and consistency in walking). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was dependent on staff for ADLs and required two or more persons to transfer her from the chair to her bed or bed to her chair. Record review of Resident #1's significant change MDS assessment dated 01/24/'2025 reflected the resident scored a 9 out of 15 on her BIMS which indicated the resident had moderate cognitive impairment and could understand others and be understood. The resident used a used a manual wheelchair for mobility. She was dependent on staff for ADLs and required two or more persons to transfer her from chair to bed or bed to chair. Record review of Resident #1's [NAME] dated 01/2025 reflected TRANSFERS: Requires maximum assistance of 2 staff with mechanical lift. Record review of Resident #1's Active Orders As of: 05/20/2025 reflected she had 3 orders of narcotic pain medications prior to the fracture of her right humerus which she was prescribed by hospice on 02/02/2024 listed as the following: 1.Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 2 hours as needed for mild pain/dyspnea. Phone Active 02/02/2024 2. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.5 ml by mouth. every 2 hours as needed for moderate pain/dyspnea. Phone Active 02/02/2024 3. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every. 2 hours as needed for severe pain/dyspnea. Phone Active 02/02/2024 Record review of the facility PIR dated 01/23/25 reflected on 01/19/2025 during a transfer from wheelchair to bed (Resident #1), CNA A heard a pop sound. LVN B (Charge Nurse on the unit) assessed, and Resident #1 told the nurse her right arm hurt. An assessment done by hospice RN C reflected she called the family, and the family did not want Resident #1 to go to the ER. The family requested she have an orthopedic appointment and to keep her comfortable. A sling was applied to stabilize her right arm and routine hospice pain medications were given. The Administrator spoke with Resident #1 and her family in Resident #1's room on 01/20/2025 at 10:00 am. Resident #1 stated she was not in pain, and she was comfortable. Treatment was provided in house and the resident stated she felt safe. CNA A was suspended pending investigation. Staff member stated she did not touch Resident #1's arm during the transfer. CNA A stated she did not use a mechanical lift and did not check the [NAME]. X-ray results were positive for a fracture the same day and Resident #1's family refused the orthopedic appointment later. Record review of Resident #1's progress note dated 01/19/2025 at 3:30 am written by LVN B reflected; resident was climbing out of bed earlier in the shift. CNA A got Resident #1 up in a wheelchair and brought her to the dining room for snacks. CNA A transferred Resident #1 back to bed and came and told him (LVN B) Resident #1's arm popped during transfer. LVN B entered the room and found Resident #1 lying in bed with a gait belt on and she complained of pain in her right arm. He wrote he did not see any obvious deformity and Resident #1 stated she would not move her arm. LVN B notified hospice, her vital signs were within normal limits and he did not attempt ROM. LVN B medicated Resident #1 with morphine sulfate, .5 ml sublingually (under the tongue) and he wrote the resident was calm. Record review of progress note written by RN C dated 01/19/2025 at 10:00 am reflected Hospice nurse came in to evaluate Resident #1 due to possible injury. Right shoulder is clearly swollen, and Resident #1 has pain to the touch. Unable to move arm without it hurting. X-ray completed. Record review of the Radiology Results Report dated 01/19/2024 at 9:55 am reflected Findings: Displaced humeral neck fracture of the right shoulder. Record review of Resident #1's progress note dated 01/20/25 written by the FNP reflected the family had 3 options: 1. send the resident to the ER. 2. call orthopedic office on Monday for further recommendation. 3. Keep the resident on hospice and control pain. The FNP's assessment of Resident #1 included: she was not in pain, had a sling in place, required maximum assistance and was mostly bed bound. Record review of Resident #1's progress note dated 01/21/25 at 2:25 pm written by RN C reflected hospice talked with orthopedic office and discussed with family who decided to keep Resident #1 in the facility and comfortable. A new order for morphine Contin 15 mg bid was provided. No pain currently. Record review of progress note written by RN C dated 01/19/2025 at 10:00 am reflected Hospice nurse came in to evaluate Resident #1 due to possible injury. Right shoulder is clearly swollen, and Resident #1 has pain to the touch. Unable to move arm without it hurting. X-ray completed. Record review of the Radiology Results Report dated 01/19/2024 at 9:55 am reflected Findings: Displaced humeral neck fracture of the right shoulder. Record review of Resident #1's progress note dated 01/20/25 written by the FNP reflected the family had 3 options: 1. send the resident to the ER. 2. call orthopedic office on Monday for further recommendation. 3. Keep the resident on hospice and control pain. The FNP's assessment of Resident #1 included: she was not in pain, had a sling in place, required maximum assistance and was mostly bed bound. Record review of Resident #1's progress note dated 01/21/25 at 2:25 pm written by RN C reflected hospice talked with orthopedic office and discussed with family who decided to keep Resident #1 in the facility and comfortable. A new order for morphine Contin 15 mg bid was provided. No pain currently. In an observation and interview on 05/20/25 at 08:45 a.m. Resident #1 was lying in bed. Resident #1 was on a low bed with a fall mat beside the bed on the floor. She stated she had a small amount of pain in her right arm but was provided pain medication. In an interview on 05/20/2025 at 08:47 am with LVN E who was Resident #1's charge nurse, she who stated Resident #1 required a mechanical lift transfer with 2 people. In an interview on 05/20/2025 at 08:50 am with CNA F who was assigned to work with Resident #1, he stated he had been at the facility for over a year and Resident #1 had always required a mechanical lift and 2 people for transfer. In an interview on 05/20/2025 at 3:00 pm with LVN B, he who stated Resident #1 was climbing out of bed and he asked CNA A to go get her up in a wheelchair and take her to the dining room for some snacks. He stated he knew how to check the [NAME], and he said Resident #1 never got up on the nightshift. He said he realized when CNA A told him Resident #1's arm popped during transfer something was wrong. He stated he entered Resident #1's room and she complained of pain, and he assessed her, medicated her, and notified the hospice of the potential injury. He stated he was accountable as the charge nurse and nursing staff received training right after that on abuse and neglect and checking the [NAME]. In an interview on 05/21/2025 at 03:09 pm with CNA A, she who stated Resident #1 did not usually get up on nightshift. She said Resident #1 had a low bed with a mat but had a fall a few nights prior and seemed to be restless, so LVN B asked her to get Resident #1 up and give her some snacks. She admitted she never had to get Resident #1 up prior to 01/19/2025. She stated she saw a gait belt sitting in a wheelchair in the resident's room and assumed she was a one-person transfer. She stated getting the resident up was no problem, but when she went to put Resident #1 back to bed, the resident jerked back, and she heard a crack or popping sound from Resident #1's right shoulder. She stated she was trained during on-boarding to check the [NAME] in PCC or to ask the nurse what type of transfer the resident needed. She stated she was trained on how to do mechanical lift transfers and needed 2 people for the transfer. She said not checking the [NAME], or asking the nurse about the right type of transfer can result in injury or harm. In an interview on 05/22/2025 at 10:03 am with the DON, she shoshe stated CNA A made a mistake and was suspended pending investigation. She stated training of all staff started the very next day. She had the Physical Therapist train staff on transfers. She stated staff received an on-boarding training with one person and they demonstrate how to do everything, and checking a resident's [NAME] is one of the items they have training on. She stated the importance of knowing the right transfer of a resident provides safety for the resident and the staff or they could get hurt. She stated CNA A received 1:1 training by the Physical Therapist on transfers prior to being allowed to work. She stated CNA A was retrained on how to access and use PCC for the [NAME], but later she resigned for other reasons . Record review of Rehabilitation Training dated 01/20/2025 provided to CNA A by the Physical Therapist reflected she had remedial training on transfers. In an interview on 05/20/2025 at 04:23 pm with CNA D who was the facility trainer revealed when staff on-board, training included the CNA would sign into PCC, then click on their station and would be able to access a resident [NAME] to check their type of required transfer. She stated she trained CNA A, and the backup plan was to ask the nurse or herself. Record review of CNA As orientation training record titled Nurse Aide Floor On-Boarding dated 09/20/2024 reflected she was trained on How to identify residents transfer ability on PCC, and mechanical lift transfers. In an interview on 05/20/2025 at 1:12 p.m. with the ADM, she who stated she was the abuse and neglect prevention coordinator. She stated CNA A was suspended pending investigation. She stated residents must feel safe at the facility. She ADM stated staff were trained immediately after the incident and she made the report. She ADM stated she was accountable for quality of care at the facility. She stated the incident was discussed in QAPI and continued to be monitored. She ADM stated 9 residents in the facility required mechanical lift transfers. Record review of the facility policy titled Abuse Prevention/Neglect or Exploitation dated 03/16/2022 reflected It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident's property. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury of harm. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility policy and procedure titled No Lift Concept dated 10/23/13 reflected requires all employees to adopt a No Lift Concept. Employees are expected to use the aid of equipment when lifting objects or residents. An educational in-service relating to safety practices and lifting is required of all employees at least one time and/or as needed. Procedure: 2. Nursing staff are required to use mechanical lifts (Hoyer, Sit-To-Stand), gait/transfer belts, sliding boards, bed scales and bed repositioning devices on residents when appropriate after being trained in their use. It was determined the failure placed Resident #1 in an IJ situation on 05/21/25. The ADM was notified on 05/21/2025 at 03:26 pm, that a PNC IJ had been identified due to the above failure. The facility implemented the following interventions: 1. CNA A was suspended pending investigation and when she returned provided 1:1 instruction for transfer and re-educated on the [NAME] and use of [NAME] prior to resident care. She later resigned. 2. On 1/20/2025 MDS coordinators completed a full audit on all residents [NAME]'s to ensure accuracy of transfer information. 3. The DON in-serviced all staff on 1/20/25 for ANE, checking the [NAME] in PCC for transfer information on residents and staff were not allowed to work until training was completed. 4. Review of new nursing staff on-boarding reflected 100% were trained in checking the [NAME] in PCC and transfers. 5. All new nursing staff continue to be in-serviced during orientation with the on-boarding checklist. 6. An Ad hoc QAPI meeting was called at 09:00 am on 01/19/2025 to discuss the incident and plan of correction. The physician was called at 6 am and the hospice RN on call was notified at 4 am. It will be discussed in quarterly QAPI meeting with the Medical Director on 05/28/2025. Observation on 05/21/2025 at 10:18 am of CNA F and CNA I perform a mechanical lift transfer for Resident #3 revealed no issues with safety and no issues with CNA F signing into PCC to check the residents [NAME]. Record review of Resident #2 and #3's MDS's, Care Plans and [NAME]'s reflected they were mechanical lift 2 person transfers. Observation on 05/21/2025 at 10:25 am of CNA J and LVN K perform a mechanical lift transfer for Resident #2 revealed no issues with safety and no issues with CNA J signing into PCC to check the residents [NAME]. Record review of training titled Checking [NAME] and Resident Transfers dated 01/20/2025 reflected 64 staff signatures. Signatures were compared to a nurse staff roster for 01/19/2025 and 100% were highlighted as had training. Record review of a notarized statement dated 05/21/25 which reflected On 01/20/2025 MDS coordinators completed a full audit on all residents [NAME]'s to ensure accuracy of transfer information. MDS coordinators continue ongoing auditing by reviewing each resident's [NAME] with every MDS completed. Signed by MDS L and MDS M. Record review of AD HOC QAPI sign in sheet dated 01/19/2025 reflected the ADM, DON, MDS M, Director of Therapy and the ADON attended. Interviews on 05/21/2025 from 10:00 am to 1:45 pm with 12-day shift nursing staff and 9-night shift nursing staff to total 20 out of 88 nursing staff employed revealed they received training after the incident on abuse and neglect, checking the [NAME] in PCC and resident transfers. In an interview on 05/21/2025 at 12:27 pm with MDS L (Day Shift), she who stated training occurred after Resident #1's incident. Staff were trained on abuse and neglect, checking the [NAME] and making sure the resident is transferred safely. In an interview on 05/21/2025 at 1:24 pm with CNA N (Night Shift), she who stated she was recently trained on abuse and neglect, checking the [NAME] in PCC for transfers, and she was trained when she on-boarded. In an interview on 05/21/2025 at 1:29 pm with CNA O (Night Shift), she who stated the ADM was the abuse and neglect coordinator. She was recently trained on abuse and neglect and checking the [NAME] for resident information. In an interview on 05/21/2025 at 1:32 pm with CNA P (Night Shift), she who stated she was recently trained to check the [NAME] for type of care a resident required. She was also trained on abuse and neglect prevention. She stated if staff was unsure of type of transfer for a resident, to check with the nurse. In an interview on 05/21/2025 at 1:35 pm with LVN Q (Night Shift) she who stated she had training on abuse and neglect. How to check [NAME] on PCC and what transfer the resident required and to ask the Charge Nurse. In an interview on 05/21/2025 at 1:38 pm with CNA S (Night Shift), she who stated in January they had training on how to access PCC and to check the [NAME] and see what type of transfer a resident needed. She stated she had training on abuse and neglect, to report an incident immediately and the ADM was the abuse and neglect prevention coordinator. In an interview on 05/21/2025 at 1:40 pm with CNA T (Day Shift), she who stated training on abuse and neglect was scheduled and on-going as needed. She stated the abuse and neglect prevention coordinator was the ADM and to report any incident immediately. She stated she had training in January on how to access the [NAME] in PCC to find out what type of transfer a resident required or to ask the nurse. In an interview on 05/21/2025 at 1:42 pm with LVN U (Day Shift), she who stated staff had recent training on checking PCC for the [NAME] which gives information on a resident such as how to transfer a resident from bed to chair. She stated as a charge nurse she needed to make sure residents are transferred safely and provided quality care. She monitored the care provided by CNAs assigned to her unit. In an interview on 05/21/2025 at 1:43 pm with RN V (Day Shift), she who stated she was one of the MDS nurses and was responsible for keeping [NAME]'s current. She stated staff were trained after the incident with Resident #1 on how to check the [NAME]. Training on abuse and neglect was provided. She stated staff were informed to report an incident right away. In an interview on 05/21/2025 at 1:44 pm with CNA W (Day Shift), he who stated he received training on how to access the [NAME] in PCC to check on a resident's care required such as transfers. He stated training was provided on abuse and neglect, and it was ongoing and as needed. In an interview on 05/21/2025 at 1:45 pm with the ADON (Day Shift), she who stated training was provided in January 2025 on how to check PCC for a resident's care needs by looking at their [NAME]. She stated she had training on abuse and neglect and provided some of the training. She stated after the incident 100% of nursing staff were trained and new people receive training on PCC, [NAME] and abuse and neglect with on-boarding. In an interview on 05/21/2025 at 1:45 pm with CMA X (Day Shift), she who stated she was provided training on signing into PCC, referring to a resident [NAME] and checking what type of care they required such as transfers. She stated she had training on abuse and neglect. In an interview on 05/21/2025 at 1:45 pm with CNA F (Day Shift), he who stated he had the training in January 2025 after the incident with Resident #1 and how to check PCC for the [NAME]. He stated he would ask the nurse if he was unsure about a resident's care. He said training was ongoing and as needed on abuse and neglect. He CNA F said the abuse and neglect prevention coordinator was the ADM. In an interview on 05/21/2025 at 2:10 pm with RN Y (Day Shift), she stated training on abuse and neglect was ongoing and as needed. She stated after the incident with Resident #1 in January 2025, all nursing staff were trained on how to check PCC for a resident [NAME] and to find out the care required such as type of transfer. She stated as a charge nurse she monitored the CNAs and resident care.

Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for 2 of 6 Residents (Resident #48 and Resident #73) whose records were reviewed. 1. The facility failed to refer Resident #48 to the stated-designated authority after she was diagnosed with Major Depressive Disorder (MDD). 2. The facility failed to refer Resident #73 to the stated-designated authority after he was diagnosed with Major Depressive Disorder (MDD), Post Traumatic Stress Disorder. This deficient practice could affect a resident with a new onset diagnosis of mental disorder, intellectual disability, or a related condition and could result in residents not receiving needed care and services for identified psychiatric problems. The findings were: 1. Review of Resident #48's face sheet, dated 12/10/24, revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke) and unspecified Dementia. Review of Resident #48's quarterly MDS assessment, dated 9/22/24, revealed her BIMS was 5 indicative of severe cognitive impairment. Review of Resident #48's Care Plan, revised on 9/23/24, revealed Resident #48 was scheduled for a psychological evaluation on 1/26/24. The results of the evaluation were not reflected in the Care Plan. Review of Resident #48's most recent psychiatric progress note, not dated revealed she was being treated for diagnosis, Major Depressive Disorder. Observation and interview on 12/11/24 at 11:05 AM revealed Resident #48 lying in bed. She engaged in conversation and was able to answer yes and no questions. It was noted she had a flat affect. Interview on 12/13/24 PM at 01:29 PM with LVN/MDS Coordinator B revealed Resident #48 had a diagnosis of MDD; was receiving Sertraline an antidepressant and psychiatric services. LVN/MDS Coordinator B stated a diagnosis of MDD would prompt them to complete another PASARR screening because it was reflective of mental illness. LVN/MDS Coordinator B stated it was important to submit another PASARR screening to ensure that first of all Resident #48 was in the right placement and to ensure the resident received needed care and services. 2. Review of Resident #73's face sheet, dated 12/13/24, revealed he was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder (PTSD), Chronic and Depression. Review of Resident #73's quarterly MDS assessment, dated 10/18/24, revealed his BIMS was 14 indicative of minimal cognitive impairment. Review of Resident #73's Care Plan, revised on 4/18/24 revealed the resident used anti-anxiety and anti-depressant medications Buspirone, Sertraline & Depakote related to anxiety, depression and PTSD. Review of Resident #73's psychiatric progress note, dated 12/9/24, revealed provider was treating Resident #73 for MDD and PTSD. It was noted that Resident #73 endorsed a history of recurrent Major Depressive Disorder and PTSD since the 1970's. Observation and interview on 12/11/24 at 10:40 AM with Resident #73 revealed he was lying down in bed. He engaged in conversation easily and stated he completed two tours in Vietnam and was 100% disabled. Interview on 12/13/24 at 01:29 PM with LVN/MDS Coordinator B revealed Resident #73 had a diagnoses of MDD and PTSD. She stated a diagnoses of MDD and or PTSD would prompt them to complete another PASARR screening because it was reflective of mental illness. She stated staff should have actually noted the diagnoses upon admission and should have completed another PASARR screening to reflect mental illness. LVN/MDS Coordinator B stated it was important to submit another PASARR screening to ensure that first of all Resident #73 was in the right placement and to ensure the resident received needed care and services. Interview on 12/13/24 at 02:07 PM with the DON revealed it was important to refer residents to PASARR for identified mental illness to ensure the residents received care and services as needed. Review of facility policy, Resident Assessment, Coordination with PASRR Program, dated 3/15/19 reflected in relevant part: Nursing facility coordinates assessments with the Preadmission screening and Resident review (PASRR) program under Medicaid to ensure that individuals with a mental illness (MI), or intellectual disability (ID), development disability (DD), or a related condition receives care and services in the most integrated setting appropriate to their needs. 9. Any resident who exhibits a newly evident or possible serious mental illness . will be promptly referred to the state mental health or intellectual disability authority for additional resident review.

Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 6 residents (Resident #146) whose records were reviewed for code status. The facility failed to obtain a DNR order for Resident #146 upon admission, [DATE], based on her Living Will, dated [DATE]. This deficient practice could affect any resident who requested a DNR code status and could result in staff providing CPR for a resident who did not want to be resuscitated. The findings were: Review of Resident #146's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction and unspecified Atrial Fibrillation. Review of Resident #146's Living Will dated [DATE] reflected she did not want cardiac resuscitation. Review of Resident #146's clinical assessment, dated [DATE], did not reflect Resident #146's code status. Review of Resident #146's Baseline Care Plan, dated [DATE], reflected full code status. Interview on [DATE] at 12:05 PM with RN A revealed physician's orders reflected Resident #146 was full code. She stated usually the Admission Coordinator would talk to the family about the resident's wishes and would pass the information to the SW. The SW would prepare a DNR if that was their wish. The charge nurse would then call the MD to get a new order for a DNR. RN A stated based on Resident #146's Living Will, dated [DATE], staff should have requested a new order for a DNR upon admission. She stated nursing staff would perform CPR as needed because they did not have a DNR order in place as of this date, [DATE]. RN A stated that would be a violation of Resident #146's rights and she would suspect Resident #146 would be upset about being resuscitated which again was not what she wanted. In addition, RN A stated Resident #146, could sustain injuries, like broken ribs, which happened frequently when providing CPR to an elderly person. That would result in Resident #146 enduring unnecessary pain. Interview with LVN/MDS Coordinator B and the SW on [DATE] at 01:15 PM revealed Resident #146's Living Will should have prompted nursing staff to obtain a request for a new order for a DNR. The SW stated typically the Admission Coordinator or the admission nurse would alert her about the resident's and family's wishes. She would then initiate an out of hospital DNR for Resident #146. LVN/MDS Coordinator B revealed a Care Plan meeting was scheduled on [DATE], but the family member did not show up and they would have discussed Resident #146's wishes for code status. Nevertheless, she stated nursing staff should have obtained a DNR physician's orders based on Resident #146's Living Will; as soon as the facility had record of it. The SW stated it was very important to ensure the resident's code status was accurate because it was the resident's life in question and their wishes. They had to ensure they followed the resident's wishes so there would not be any catastrophic consequences. The SW stated she had not been notified of Resident #146's wish for DNR code status and had not talked to the family. Interview on [DATE] at 02:07 PM the DON stated it was very important nursing staff obtained a DNR order in honoring Resident #146's wishes. She stated the facility had multiple safeguards in place to ensure a resident's code status was accurate. The DON also stated the Admission Coordinator would be the first person to discuss the resident's code status with the nurse transferring the resident to their facility. The Admission Coordinator would pass on the information to the SW and the admitting nurse would also discuss the code status with the family upon admission. The family would sign the Admission Agreement which reflected the code status was discussed with the family. The admitting nurse would enter the code status on the admission assessment. The DON stated the family signed the Admission Agreement on [DATE]. The DON stated she understood the code status on the physician's order for [DATE]. The DON stated unfortunately sometimes the family would go against the wishes of the resident. Telephone interview on [DATE] at 2:53 PM with Resident #146's family member revealed nursing staff called today asking her to sign paperwork for the resident's code status. She stated she did not know about Resident #146's Living Will but if Resident #146 wished not to be resuscitated then she would honor the resident's wishes. She stated she had not discussed Resident #146's code status with staff prior to this date, [DATE]. Review of facility policy, Advance Directive Documentation, dated [DATE], reflected in relevant part: All residents and or responsible party, at the time of the admission to the facility, are provided with information related to the resident's right under Texas to make decisions concerning medical care, include the right to accept or refuse medical or surgical treatment and the right to formulate advance directives. This facility respects the implementation of such rights and will follow physician's orders respecting such rights. Without physician's orders, facility staff may be required to institute interventions differ from the advanced directives.

Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 5 residents (Residents #38) reviewed for reporting allegations of abuse and neglect. CNA C failed to report an incident of suspected abuse, from 11/09/2024, to the abuse and neglect coordinator until 11/11/2024 resulting in the allegation not being reported to the State Survey agency (HHSC) within the required 2 hours for suspected abuse. This deficient practice could place residents at risk for continued abuse and neglect. The findings included: Record review of Resident #38's face sheet dated 12/11/2024 revealed resident was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #38 had diagnoses that included Alzheimer's disease and unspecified dementia. Record review of the facility provided Provider Investigation Report dated 11/11/2024 revealed the incident was observed on 11/09/2024, time not recorded, and reported to HHSC on 11/11/2024 at 10:40 AM. CNA C reported to the Scheduler that she observed CNA D shoot the finger (flip the resident off with her the middle finger) at Resident #38. Interview with the Administrator on 12/12/2024 at 4:35 PM revealed she was the abuse and neglect coordinator. The Administrator stated all staff received training on when to report abuse and neglect, when they start employment and again annually or in response to incidents. Administrator also stated that there are signs hanging on each unit identifying the administrator as the abuse and neglect coordinator and her phone number. The Administrator stated that CNA C reported an incident that occurred on 11/09/2024 day shift, 6 AM to 2 PM, to the Scheduler on 11/11/2024 via phone. The Administrator stated the Scheduler reported the incident to her right away, she then reported it to HHSC and began the internal investigation. CNA C was counseled on when suspicions of abuse, neglect and exploitation needed to be reported. The Administrator went on to say she completed an in-service with all staff when to report abuse, neglect and exploitation on 11/12/2024 in response to the incident. Interview with the Scheduler on 12/13/2024 at 11:44 AM revealed CNA C called them on 11/11/2024 to report that she witnessed CNA D give Resident #38 the finger while they were providing care to Resident #38 on 11/09/2024. CNA C did not provide the time of the incident. The Scheduler stated CNA C was questioned why the incident was not reported to the Administrator who was the abuse and neglect coordinator. CNA C told them she did not want to get CNA D in trouble. Interview with CNA D on 12/13/2024 at 12:18 PM revealed CNA D stated she did not flip off Resident #38. She stated that she and other staff had issues with the CNA C. She stated the date in question, she was performing rounds with the nurse and when asked about certain residents and their care, she stated that those residents were on a hall assigned to CNA C. She stated that the nurse was concerned that some of the residents had not received care. She stated that had been an ongoing issue with that CNA not performing her duties and then blaming other staff. CNA D stated that she had since gained employment at another facility, and she was not returning to this facility due to the staff dynamics with CNA C. Interview with CNA C on 12/13/2024 at 1:04 PM revealed she worked the morning shift, 6 AM to 2 PM, on Saturday 11/09/2024 with CNA D. CNA D was assigned to Resident #38. CNA C stated that CNA D reported Resident #38 refused care from CNA D. CNA D asked CNA C to assist changing Resident #38. CNA C stated while she and CNA D were changing the resident, Resident #38 started to make remarks such as President Trump will send you back you your country. CNA C stated CNA D responded to Resident #38 saying I have papers and then flipped the resident the middle finger. CNA C asked CNA D to leave the room while CNA C completed care. CNA C stated the resident was calm and did not react to CNA D's gesture. CNA C discussed the incident with CNA D and told her flipping the middle finger was inappropriate. CNA C stated she did not report the incident to her supervisor or the Administrator right away because she did not want to get CNA D in trouble and Resident #38 was not upset by the incident. CNA C stated she received training on when to report abuse, neglect, and exploitation when she was hired and annually and in response to incident. Record review of facility policy named Abuse Prevention dated 08/29/2019 revealed 1. Reporting of all alleged violations to the Administrator, state agency, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury

Based on observation, interview and record review the facility failed to ensure the assessment must accurately reflect the resident's status for 2 of 6 Residents (Resident #48 and Resident #73) whose records were reviewed for assessments. 1. MDS staff failed to include Resident #48 was diagnosed with Major Depressive Disorder on her most recent quarterly MDS assessment, dated 9/22/24. 2. MDS staff failed to include Resident #73 was diagnosed with Major Depressive Disorder, Post Traumatic Stress Disorder on his most recent quarterly MDS assessment, dated 10/18/24. This deficient practice could affect any resident and could result in Residents not receiving needed care and services. The findings were: 1. Review of Resident #48's face sheet, dated 12/10/24, revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke) and unspecified Dementia. Review of Resident #48's Care Plan, revised on 9/23/24, revealed Resident #48 was scheduled for a psychological evaluation on 1/26/24. The results of the evaluation were not reflected in the Care Plan. Review of Resident #48's psychiatric progress note, not dated, revealed she was being treated for diagnosis to include Major Depressive Disorder. Review of Resident #48's physician's orders for December 2024 revealed an order for Sertraline HCI tablet, 25 MG Give 1 tablet by mouth one time a day for Depression Prescriber Written Active 02/06/2024 02/06/2024. Review of Resident #48's quarterly MDS assessment, dated 9/22/24, revealed her BIMS was 5 indicative of severe cognitive impairment. It did not reflect Resident #48 had a diagnosis of Major Depressive Disorder. Further review revealed she received an anti-depressant. Observation and interview on 12/11/24 at 11:05 AM revealed Resident #48 lying in bed. She engaged in conversation and was able to answer yes and no questions. It was noted she had a flat affect. Interview on 12/13/24 PM at 01:29 PM with LVN/MDS Coordinator B revealed Resident #48 had a diagnosis of Major Depressive Disorder and was receiving Sertraline, an antidepressant. LVN/MDS Coordinator B stated Resident #48's quarterly MDS assessment, dated 9/22/24, did not reflect that she had MDD or that she was receiving Sertraline. She stated it was important Resident #48's MDS assessment reflect an accurate status of the resident to ensure the resident received needed care and services. 2. Review of Resident #73's face sheet, dated 12/13/24, revealed he was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder (PTSD), Chronic and Depression. Review of Resident #73's quarterly MDS assessment, dated 10/18/24, revealed his BIMS was 14 indicative of minimal cognitive impairment. The MDS assessment did not reflect Resident #73 had a chronic diagnoses of PTSD. Review of Resident #73's Care Plan, revised on 4/18/24 revealed the resident used anti-anxiety and anti-depressant medications Buspirone, Sertraline & Depakote related to anxiety, depression and PTSD. Review of Resident #73's psychiatric progress note, dated 12/9/24 revealed the provider was seeing Resident #43 for Major Depressive Disorder and PTSD. It was noted that Resident #43 endorsed a history of recurrent Major Depressive Disorder and PTSD since the 1970's. Observation and interview on 12/11/24 at 10:40 AM with Resident #73 revealed he completed two tours in Vietnam and was 100% disabled. He engaged in conversation and was able to answer surveyor's questions. Interview on 12/13/24 at 01:29 PM LVN/MDS Coordinator B stated Resident #73 had a diagnoses of Major Depressive Disorder and PTSD. She stated those diagnoses were not reflected in Resident #73's quarterly MDS assessment dated [DATE]. LVN/MDS Coordinator B it was important Resident #73's MDS assessment reflected an accurate status of the resident to ensure the resident received needed care and services. Interview on 12/13/24 at 02:07 PM the DON stated it was important that a resident's MDS assessment and care plan accurately reflected their status because nursing staff had access to these tools. She stated staff used them as a guide to help them understand a resident's needs and to provide the care and services based on the assessment and care plan. Review of facility policy, Minimum Data Set 3.0 dated 1/19/14 revealed: An MDS 3.0 will be completed for each [facility name] Resident: on admission, quarterly, annually, and when a significant change in condition occurs. The Medicare MDS will be done per PPS guidelines and time frames. Review of cms.gov website, DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services dated February 2016 reflected in relevant part: Skilled Nursing Facilities (SNFs) must assess the clinical condition of residents by completing required Minimum Data Set (MDS) 3.0 assessments. The Medicare-required PPS assessment schedule includes 5-day, 14-day, 30-day, 60-day, and 90-day scheduled assessments. Except for the first assessment (5-day assessment), each assessment is scheduled according to the resident's length of stay in Medicare-covered Part A care. Conducting the Assessment: Each assessment must: Accurately reflect the resident ' s status.

Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 14 of 16 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #16) reviewed for mechanical soft diet needs. 1. The facility failed to follow the Speech Language Pathologist's (SLP) recommendations to grind meat for Resident #16's mechanical soft diet, served Resident #16 a ham sandwich, with 2 slices of ham lunch meat, each doubled in half; Resident was found shortly after unresponsive, received Cardio Pulmonary Resuscitation (CPR), was sent to the hospital via Emergency Medical Services (EMS) where she died due to a Difficult airway with lots of debris as quoted by the physician. 2. The facility assessed residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 with the need for a mechanical soft diet and prepared with the intent to serve to them ham sandwiches with sliced ham lunch meat, not ground. An Immediate Jeopardy (IJ) was identified on 06/23/2024. While the IJ was removed on 06/27/2024, the facility remained out of compliance at a scope of pattern with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for harm, up to and including death, by not providing residents with their correct diet textures. The findings include: 1. A record review of Resident #16's admission record dated 06/22/2024, revealed an admission date of 07/10/2023 with diagnoses which included muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass), dysphasia (difficulty swallowing), dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #16's significant change MDS assessment dated [DATE] revealed Resident #16 was a [AGE] year-old female admitted for long term care, assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #16 could be understood with clear speech and could understand others. Resident #16 had adequate hearing and had a need for corrective glasses. Resident #16 used a wheelchair. A review of the Functional Abilities and Goals section revealed Resident #16 was assessed for eating, 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 . A record review of Resident #16's care plan dated 06/22/2024 revealed, NUTRITION (Resident #16) is at risk for malnutrition DT (due to) DX (diagnosis) Muscular Dystrophy, Dysphagia, .vascular Dementia, decreased independence, age, wc (wheelchair) bound, requires assist, mechanical soft diet, .Provide diet as ordered: .Mechanical Soft Texture, Thin Liquids .Monitor for signs/symptoms of dysphagia (swallowing problems) and report to nurse/MD .(Resident #16) has GERD (gastro esophageal reflux disease) r/t (related to) hyperacidity .Monitor / document / report PRN (as needed) s/sx (signs and symptoms) of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, N/V (nausea vomiting), Indigestion, Regurgitation, increased salivation, swallowing problems, bitter taste in mouth, Dysphagia, substernal chest pain, increased gag response A record review of Resident #16's Speech Therapy Plan of Care (Evaluation Only) dated 07/12/2023, revealed, Reason for referral: this [AGE] year-old female presents for speech language pathology evaluation of cognitive communication and swallow status following hospitalization for syncope (fainting) episodes. Patient has (a) history of dysphagia (swallowing difficulties) due to C P Bar (the failure of the muscle at the top of the throat which closes and prevents food from coming back up) and complicated by myotonic muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass) .will continue on mechanical soft solids at this time due to narrowing (throat) .Precautions: fall risk, full code (staff perform CPR), cardiac / mechanical soft (grind meats) / thin liquids, aspiration precautions. Discharge Plans: patient will remain at this facility with full time caregiver support A record review of Resident #16's physicians orders dated 06/22/2024, revealed on 08/22/2023 the physician ordered for Resident #16 to be served a mechanical soft diet texture. A record review of Resident #16's PT - Therapist Progress & Updated Plan of Care dated 05/14/2024, was reviewed and signed by the physician on 05/30/2024 which read, precautions: fall risk, full code, cardiac / mechanical soft (grind meat) / thin liquids, aspiration precautions. Able to self monitor and correct. A record review of Resident #16's meal ticket, Thursday - June 20,2024 .please select menu choices .ham and cheese sand .mechanical soft .eats in room. During an interview and observation on 06/22/2024 at 01:07 PM the Assistant Food Service Manager (AFSM) stated the kitchen prepares and serves residents with a need for mechanical soft diet textures ham and cheese sandwiches. The AFSM provided a recipe for the ham and cheese sandwich, and the Alternate Menu Spreads document. The AFSM stated the Alternate Menu was reviewed and approved by the facility's registered dietician. The AFSM stated the alternate menu specified a Resident with a need for a mechanical soft diet could be served a ham sandwich. The AFSM demonstrated a ham sandwich which was prepared and available to be served to a Resident with a mechanical soft diet. The sandwich was wrapped in a clear plastic wrap. The AFSM unwrapped the sandwich and demonstrated the sandwich on a plate by removing the top slice of bread which revealed 2 slices of ham doubled in half and laid side by side on the bottom half of the sandwich. A record review of the undated alternative menu spreads revealed a ham sandwich was listed as yes / thin slices under the column for mechanical. A record review of the facility's Ham and Cheese Sandwich recipe dated 05/15/2024 revealed, .Smoked boneless pork ham, sliced thin, 2 oz., cheese, American, sliced, 0.5 oz., bread, white, slice .layer 2 oz. of ham and ½ oz. cheese on 1 slice of bread. Top with other slice During an interview on 06/22/2024 at 02:28 PM the Food Service Manager FSM stated the kitchen used an alternative menu spread which listed a ham and cheese sandwich has compatible with mechanical soft diet textures and could be served to residents who have a need for mechanical soft diet textures. The FSM stated the alternative menu spread was reviewed and approved by the RD on 11/13/2023. A record review of the facility's nursing schedule dated 06/20/2024 revealed CNA A, RN B, and Medication Aide C (MA C) worked Resident #16's hall from 07:00 AM to 07:00 PM. During an interview on 06/22/2024 at 11:00 AM with CNA A stated he has worked at the facility since 10/23/2023. CNA A stated Resident #16 was cool - she was calm, nice, and she liked coffee and hot tea .she could not walk, she was bed bound, she was recovering from a fractured leg, and she lived on the second floor. CNA A stated he worked Thursday 06/20/2024 from 07:00 AM to 07:00 PM, it was a normal day . at dinner time, around 06:00 PM, MA C and I helped serve residents their meals .I did not serve Resident #16 . I was in the room across from Resident #16 .I heard a call light and came out and saw (Resident #16's) call light, I went in, and I saw Resident #16 seated in her wheelchair with a distressed look on her face, gasping for air. I called and yelled for RN B, I swept Resident #16's mouth and discovered some food, it looked like bread. RN B arrived; we repositioned Resident #16 on the floor. RN B called out for help, and we continued to sweep Resident #16's mouth, we were finding pieces of food, bread .MA C came in the room and RN B told her to bring the crash cart (a cart supplied with CPR supplies) and call 911, we began CPR with RN B performing chest compressions. MA C returned with the crash cart, and we began using the AED (automatic external defibrillator) and the suction machine to suck out food from Resident #16's mouth / throat; we continued CPR with RN B doing chest compressions and I provided rescue breathing with the bag, we took turns about 2x each when EMS arrived and took over. During an interview on 06/22/2024 at 11:15 AM MA C stated she has worked at the facility 13 years. MA C stated Resident #16 was nice and sweet .she took her pills whole .she had a wheelchair. MA C stated she served residents their meals. MA C stated the kitchen prepared and delivered the residents' meals to the unit in a meal cart. MA C stated on 6/20/2024, she retrieved Resident #16's dinner from the cart and served Resident #16 her dinner, which consisted of a ham sandwich and then proceeded to serve other residents. MA C stated Resident #16 ate in her room. MA C stated she was alerted to Resident #16's room where she saw RN B and CNA A providing CPR to Resident #16 on the floor. MA C stated RN B called for MA C to bring the crash cart and call 911. MA C stated she returned with the crash cart. MA C stated she called 911 on her cell phone at 06:37 PM, and then made the path clear for EMS. MA C stated she went to the front door to guide EMS to Resident #16 once they arrived. During an interview on 06/22/2024 at 01:27 PM RN B stated Resident #16 would prefer to eat in her room. RN B stated Resident #16 had a need for a mechanical soft diet but would often refuse her diet texture, for example she would eat bacon for breakfast. RN B stated on 06/20/2024 at dinner time, around 06:00 PM, she was assisting and providing care for another Resident. RN B stated she had not reviewed residents' dinner meal trays for safety and CNA A and MA C were serving residents their dinner meals. RN B stated had she reviewed Resident #16's sandwich she may not have seen the ham was sliced and not ground per mechanical soft diet texture protocol due to the sandwiches are wrapped and she did not routinely unwrap sandwiches. RN B stated she believed the kitchen prepared sandwiches for mechanical soft diet textures with ground lunch meats, like ham salad. RN B stated she was assisting another Resident in their room when she heard CNA A calling for her in Resident #16's room. RN B stated she immediately went to the room and discovered CNA A and Resident #16 in her wheelchair. Resident #16 was not breathing and was distressed. RN B stated she and CNA A began sweeping Resident #16's mouth and removed food debris. RN B stated she called out for help and MA C arrived, I told her to bring the crash cart and call 911. RN B stated MA C returned with the crash cart and she and CNA A used the suction machine and continued to remove food debris. RN B stated Resident #16 became unresponsive without a pulse and breath. RN B stated she and CNA A repositioned Resident #16 to the floor and began CPR with the use of the AED. RN B stated she and CNA A took turns and turned over CPR to the EMS paramedics when they arrived. A record review of Resident #16's hospital history and physical record, dated 06/20/2024 revealed Resident #16 was admitted to the emergency room at the local hospital at 09:11 PM, Patient admission date: 06/20/2024 at 21:11 (09:11 PM) BIBEMS (brought in by EMS), from nursing home after choking episode and cardiopulmonary arrest. EMS obtained ROSC (return of spontaneous circulation) after 20 minutes of CPR / ACLS (cardiopulmonary resuscitation / advanced cardiac life support). Difficult airway with lots of debris thus LMA (Laryngeal Mask Airway, a tube inserted down the throat to facilitate the airway) used until definitive airway obtained at (hospital) emergency room by emergency room physician using [NAME] ([NAME], a guide for an airway tube to be inserted). Patient hypotensive (very low blood pressure) .Reportedly mental status notable for repetitive twitching motion. During my exam flaccid after RSI (rapid sequence induction) drugs with pupils 4mm appeared fixed. Significantly hypoxic (severe low blood oxygen) with bilateral multifocal infiltrates (both the left and the right have widespread debris) on x-ray. Requiring aggressive pulmonary toilet by respiratory therapist (suctioning the airway to remove debris and mucus) irrigation and suction frequently currently requiring 100% oxygen) A record review of Resident #16's hospital Discharge Summary record, dated 06/20/2024 revealed Resident #16's physician pronounced Resident #16's death at 11:06 PM, During nursing care assessment (of) patient rhythm converted to asystole (also known as flatline, a state of standstill for the heart) and patient noted pulseless. CPR per ACLS initiated and code blue called .discussion initiated with (family representative) in waiting room current status and plan for proceeding. Informed suspicion for anoxic brain injury (severe brain cell death resulting in permanent cognition loss) given information that patient (was) found down arrested (unresponsive) and ROSC after 20 minutes (brain injury can begin after 4 minutes) .(family member) was offered and requested to witness active resuscitation efforts and at that time surrogate decision was made by (family member) to terminate efforts .time of death called at 23:06 (11:06 PM) . preliminary cause of death: choking / severe aspiration (when food and or drink are sucked into the airway and lungs). During an interview on 06/22/2024 at 11:38 AM the DON stated she believed the ham sandwich with thinly sliced ham was compatible for residents who required mechanical soft diets. The DON stated the plan was developed by the RD to support residents with the need for mechanical soft diets. During an interview on 06/22/2024 at 01:30 PM the RD stated she had reviewed and approved the facility's alternative menu spreads to include the compatibility of a ham sandwich with thinly sliced ham with the needs of residents who required mechanical soft diets. The RD stated her research and use of professional standard resources supported the compatibility of a ham sandwich with thinly sliced ham with the needs of residents who required mechanical soft diets. The RD stated the rationale was to improve residents' compliance with their diet textures and thereby improve nutritional intake and over all mitigate weight loss and malnutrition. During an interview on 06/22/2024 at 05:00 PM the SLP stated Resident #16 had a difficult swallow response due to the muscle atop of her throat was not functioning well. The muscle referred to as the CP was weak and would allow food to come back up reflux and could enter the airway. The SLP referred to the situation as a CP bar and was complicated by Resident #16's muscular dystrophy and history of strokes. The SLP stated she had evaluated Resident #16 and had recommended Resident #16 to be served a mechanical soft diet specific for ground meats. The SLP stated her definition of mechanical soft would be like the International Dysphagia Diet Standardization Initiative's level 5. The SLP stated her expectation for mechanical soft would include foods which were soft and moist, with no liquid leaking / dripping from the food, where biting is not required, minimal chewing was required, lumps of 4mm in size, lumps can be mashed with the tongue, food could be easily mashed with just a little pressure from a fork, food should be able to be scooped onto a fork, with no liquid dripping and no crumbles falling off the fork. The SLP stated she did not believe a ham sandwich met those requirements. The SLP stated she believed the meats should be ground for a mechanical soft diet and stated a ham sandwich could be served as a ham salad sandwich for residents who required a mechanical soft diet. The SLP stated Resident #16's risk for not receiving mechanical soft foods was choking and aspiration. During an interview on 06/22/2024 at 05:50 PM the Administrator stated she believed the ham sandwich with thinly sliced ham was appropriate for residents who required mechanical soft diets. The Administrator stated she stated she had confidence in the professional guidance from the RD was to support residents with a mechanical soft diet with the lunchmeat sandwiches made with thinly sliced meat. During an interview on 06/23/2024 at 06:10 PM NP L stated she had conferenced with the Medical Director and at this time could not offer opinions on the compatibility for a ham sandwich as prepared and served by the facility for the remaining residents at the facility who were ordered a mechanical soft diet. During an interview on 06/23/2024 at 07:04 PM NP L stated she was the NP for Resident #16. NP L stated she and the Medical Director reviewed Resident #16's medical record and believed a ham sandwich with thinly shaved ham could have been safe for Resident #16 to consume per her mechanical soft diet. 2. A record review of the facility's diet type report dated 06/22/2024 revealed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were identified as in need of a mechanical soft diet texture. A record review of Resident #1's admission record dated 06/27/2024 revealed an admission date of 04/20/2020 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #1's ST - Therapist Progress & Discharge Summary dated 03/07/2024 revealed the SLP recommended Resident #1 was to receive a mechanical soft diet texture. A record review of Resident #1's care plan dated 06/27/2024 revealed Resident #1 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #2's admission record dated 06/27/2024 revealed an admission date of 08/05/2022 with diagnoses which included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior) and dysphagia (difficulty swallowing). Further review revealed Resident #2 was an [AGE] year-old female. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a need for a mechanical altered diet. A record review of Resident #2's physician's orders dated 06/27/2024 revealed Resident #2 was ordered on 09/28/2023 to receive a mechanical soft diet texture. A record review of Resident #2's care plan dated 06/27/2024 revealed, provide diet as ordered .mechanical soft texture A record review of Resident #3's admission record revealed an admission date of 10/01/2021 with diagnoses which included dementia (affects memory, thinking, and behavior) and dysphagia (difficulty swallowing). Further review revealed Resident #3 was a [AGE] year-old female. A record review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 had a need for a mechanical altered diet. A record review of Resident #3's physician's orders dated 06/27/2024 revealed Resident #3 was ordered on 09/05/2023 to receive a mechanical soft diet texture. A record review of Resident #3's care plan dated 06/27/2024 revealed, provide diet as ordered .mechanical soft texture A record review of Resident #4's admission record revealed an admission date of 12/30/2016 with diagnoses which included dementia (affects memory, thinking, and behavior) and dysphagia (difficulty swallowing). Further review revealed Resident #4 was a [AGE] year-old male. A record review of Resident #4's physician's orders dated 06/27/2024 revealed Resident #4 was ordered on 08/14/2023 to receive a mechanical soft diet texture. A record review of Resident #4's care plan dated 06/27/2024 revealed, provide diet as ordered .mechanical soft texture A record review of Resident #5's admission record revealed an admission date of 03/23/2022 with diagnoses which included Alzheimer's disease (a type of dementia which affects memory, thinking, and behavior) and dysphagia (difficulty swallowing). Further review revealed Resident #5 was an [AGE] year-old female. A record review of Resident #5's quarterly MDS assessment dated [DATE] revealed Resident #5 had a need for a mechanical altered diet. A record review of Resident #5's ST - Therapist Progress & Discharge Summary dated 09/05/2023 revealed the SLP recommended Resident #5 was to receive a mechanical soft diet texture. A record review of Resident #5's care plan dated 06/27/2024 revealed, provide diet as ordered .mechanical soft texture A record review of Resident #6's admission record dated 06/27/2024 revealed an admission date of 02/01/2024 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 was an [AGE] year-old male admitted for care requiring a mechanical soft diet texture. A record review of Resident #6's physician's orders dated 06/27/2024 revealed Resident #6 was ordered on 02/01/2024 to receive a mechanical soft diet texture. A record review of Resident #6's care plan dated 06/27/2024 revealed Resident #6 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #7's admission record dated 06/27/2024 revealed an admission date of 03/07/2024 with diagnoses which included dysphagia (difficulty swallowing). A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was an [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #7's physician's orders dated 06/27/2024 revealed Resident #7 was ordered on 03/21/2024 to receive a mechanical soft diet texture. A record review of Resident #7's care plan dated 06/27/2024 revealed Resident #7 required a mechanical soft diet texture. A record review of Resident #8's admission record dated 06/27/2024 revealed an admission date of 10/22/2020 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #8's quarterly MDS assessment dated [DATE] revealed Resident #8 was an [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #8's physician's orders dated 06/27/2024 revealed Resident #8 was ordered on 06/17/2024 to receive a mechanical soft diet texture. A record review of Resident #8's care plan dated 06/27/2024 revealed Resident #8 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #9's admission record dated 06/27/2024 revealed an admission date of 05/26/2023 with diagnoses which included dysphagia (difficulty swallowing). A record review of Resident #9's quarterly MDS assessment dated [DATE] revealed Resident #9 was an [AGE] year-old male admitted for care requiring a mechanical soft diet texture. A record review of Resident #9's physician's orders dated 06/27/2024 revealed Resident #9 was ordered on 08/14/2023 to receive a mechanical soft diet texture. A record review of Resident #9's care plan dated 06/27/2024 revealed Resident #9 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #10's admission record dated 06/27/2024 revealed an admission date of 09/10/2016 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #10's quarterly MDS assessment dated [DATE] revealed Resident #10 was a [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #10's physician's orders dated 06/27/2024 revealed Resident #10 was ordered on 08/14/2023 to receive a mechanical soft diet texture. A record review of Resident #10's care plan dated 06/27/2024 revealed Resident #10 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #11's admission record dated 06/27/2024 revealed an admission date of 01/06/2021 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #11's physician's orders dated 06/27/2024 revealed Resident #11 was ordered on 12/15/2023 to receive a mechanical soft diet texture. A record review of Resident #11's care plan dated 06/27/2024 revealed Resident #11 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #12's admission record dated 06/27/2024 revealed an admission date of 12/23/2023 with diagnoses which included Myopathy (a disease of the muscle in which the muscle fibers do not function properly. Myopathy means muscle disease) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #12's physician's orders dated 06/27/2024 revealed Resident #12 was ordered on 01/02/2024 to receive a mechanical soft diet texture. A record review of Resident #12's care plan dated 06/27/2024 revealed Resident #12 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #13's admission record dated 06/27/2024 revealed an admission date of 02/23/2019 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #13's quarterly MDS assessment dated [DATE] revealed Resident #13 was a [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #13's physician's orders dated 06/27/2024 revealed Resident #13 was ordered on 09/04/2023 to receive a mechanical soft diet texture. A record review of Resident #13's care plan dated 06/27/2024 revealed Resident #13 resided in the memory care unit and required a mechanical soft diet texture. Record review of policies for Resident Food Services with the subject Diet Orders and Other Resident Information (policy #C203, date issued- 5/95; revised date 01/24) on 6/25/2024 at 4:26PM revealed the policy stated: Diet orders should be determined with the resident or responsible party and in accordance with his/her informed choices, goals, and preferences. The responsible physician or designee or qualified dietician/other clinically qualified nutrition professional per state regulations, must order the diet in writing. The community may delegate the task of writing diet orders to a Registered Dietician who is acting within the scope of practice as defined by state law and is under the supervision of a physician. Nursing is responsible for communicating all nutrition related information to the Food and Nutrition department per community protocol. A record review of the International Dysphagia Diet Standardization Initiative's website, https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/5_Minced_Moist_Adults_consumer_handout_30Jan2019.pdf Accessed 06/23/2024, Revealed, Minced and Moist, level 5, minced and moist food for adults; what is this food texture level? Level 5 - minced and moist foods: Soft and moist, but with no liquid leaking / dripping from the food. Biting is not required. minimal chewing required. lumps of 4mm in size. food can be easily managed with just a little pressure from a fork. should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork. Why is this food texture level used for adults? Level 5 minced and moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food but are not able to chew it down into little pieces that are safe to swallow. Minced and moist foods only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It is important that minced and moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or fork . Examples of level 5 minced and moist foods for adults, meat served finely minced or chopped to 4mm lump size served in a thick smooth, non-pouring sauce or gravy .no regular dry bread due to high choking risk! Missing The facility's Administrator was notified and presented with a IJ template on 06/23/2024 at 07:00 PM, a Plan of Removal was requested from the facility. The following Plan of Removal submitted by the facility was accepted on 06/27/2024. Plan of Removal IJ Immediacy Removal Plan F 805 Facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs 06/23/2024. 1. All thin sliced meat options designated for mechanical soft diets were removed from all SNF units, (Unit 1), (unit 2), and (memory care). 6-23-24 2. Dietary Policy, Dietary Spread Sheets, and Dietary Menus were revised to show that all thin sliced meat options designated for Mechanical Soft Diets were removed and appropriate alternates noted. 6-23-24 3. All Staff working in facility were in-serviced by noon on 6-25-24 on Policy #C203 and #C219 , Titled Diet Orders and Other Resident Information and Snacks. The changes removed sandwiches with thinly sliced meats from all documents. In addition, Nursing Unit Stock Item List was updated, Seasonal Menu and Spreadsheets were updated to also reflect removal of thinly sliced meat as an option for mechanical soft diets. These policies will be available for reference by staff located in the Food Service Office, the Facility shared drive and presented as a visual for in-services. 4. Dietary Manager or Dietary Designees will monitor kitchen and all unit refrigerators routinely to ensure that appropriate sandwich options are available. 6-24-24 The Dietary Manager or Designee will be assigned to monitor tray line and sign off as to compliance of correct texture as ordered each meal for 14 days, then each meal twice a week for two weeks then three meal services once a week for 3 months. Administrator or Designee will follow up with meal tray monitor/audit twice a week for 3 months, at random meals to ensure tray line accuracy. Results to be reported to QAPI. <b[TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to ensure each resident the residents environment remained as free of accident hazards as was for 1 of 14 Residents (#16) reviewed for mechanical soft diet needs and supervision. 1.The facility failed to follow the Speech Language Pathologist's (SLP) recommendations to grind meat for Resident #16's mechanical soft diet, served Resident #16 a ham sandwich, with 2 slices of ham lunch meat, each doubled in half; Resident was found shortly after unresponsive, received Cardio Pulmonary Resuscitation (CPR), was sent to the hospital via Emergency Medical Services (EMS) where she died due to a Difficult airway with lots of debris as quoted by the physician. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for harm, up to and including death, by not providing residents with their correct diet textures. The findings include: 1. A record review of Resident #16's admission record dated [DATE], revealed an admitted [DATE] with diagnoses which included muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass), dysphasia (difficulty swallowing), dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #16's significant change MDS assessment dated [DATE] revealed Resident #16 was a [AGE] year-old female admitted for long term care, assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #16 could be understood with clear speech and could understand others. Resident #16 had adequate hearing and had a need for corrective glasses. Resident #16 used a wheelchair. A review of the Functional Abilities and Goals section revealed Resident #16 was assessed for eating, 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 . A record review of Resident #16's care plan dated [DATE] revealed, NUTRITION (Resident #16) is at risk for malnutrition DT (due to) DX (diagnosis) Muscular Dystrophy, Dysphagia, .vascular Dementia, decreased independence, age, wc (wheelchair) bound, requires assist, mechanical soft diet, .Provide diet as ordered: .Mechanical Soft Texture, Thin Liquids .Monitor for signs/symptoms of dysphagia (swallowing problems) and report to nurse/MD .(Resident #16) has GERD (gastro esophageal reflux disease) r/t (related to) hyperacidity .Monitor / document / report PRN (as needed) s/sx (signs and symptoms) of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, N/V (nausea vomiting), Indigestion, Regurgitation, increased salivation, swallowing problems, bitter taste in mouth, Dysphagia, substernal chest pain, increased gag response A record review of Resident #16's Speech Therapy Plan of Care (Evaluation Only) dated [DATE], revealed, Reason for referral: this [AGE] year-old female presents for speech language pathology evaluation of cognitive communication and swallow status following hospitalization for syncope (fainting) episodes. Patient has (a) history of dysphagia (swallowing difficulties) due to C P Bar (the failure of the muscle at the top of the throat which closes and prevents food from coming back up) and complicated by myotonic muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass) .will continue on mechanical soft solids at this time due to narrowing (throat) .Precautions: fall risk, full code (staff perform CPR), cardiac / mechanical soft (grind meats) / thin liquids, aspiration precautions. Discharge Plans: patient will remain at this facility with full time caregiver support A record review of Resident #16's physicians orders dated [DATE], revealed on [DATE] the physician ordered for Resident #16 to be served a mechanical soft diet texture. A record review of Resident #16's PT - Therapist Progress & Updated Plan of Care dated [DATE], was reviewed and signed by the physician on [DATE] which read, precautions: fall risk, full code, cardiac / mechanical soft (grind meat) / thin liquids, aspiration precautions. Able to self monitor and correct. A record review of Resident #16's meal ticket, Thursday - [DATE] .please select menu choices .ham and cheese sand .mechanical soft .eats in room. During an interview and observation on [DATE] at 01:07 PM the Assistant Food Service Manager (AFSM) stated the kitchen prepares and serves residents with a need for mechanical soft diet textures ham and cheese sandwiches. The AFSM provided a recipe for the ham and cheese sandwich, and the Alternate Menu Spreads document. The AFSM stated the Alternate Menu was reviewed and approved by the facility's registered dietician. The AFSM stated the alternate menu specified a Resident with a need for a mechanical soft diet could be served a ham sandwich. The AFSM demonstrated a ham sandwich which was prepared and available to be served to a Resident with a mechanical soft diet. The sandwich was wrapped in a clear plastic wrap. The AFSM unwrapped the sandwich and demonstrated the sandwich on a plate by removing the top slice of bread which revealed 2 slices of ham doubled in half and laid side by side on the bottom half of the sandwich. A record review of the undated alternative menu spreads revealed a ham sandwich was listed as yes / thin slices under the column for mechanical. A record review of the facility's Ham and Cheese Sandwich recipe dated [DATE] revealed, .Smoked boneless pork ham, sliced thin, 2 oz., cheese, American, sliced, 0.5 oz., bread, white, slice .layer 2 oz. of ham and ,d+[DATE] oz. cheese on 1 slice of bread. Top with other slice During an interview on [DATE] at 02:28 PM the Food Service Manager FSM stated the kitchen used an alternative menu spread which listed a ham and cheese sandwich has compatible with mechanical soft diet textures and could be served to residents who have a need for mechanical soft diet textures. The FSM stated the alternative menu spread was reviewed and approved by the RD on [DATE]. A record review of the facility's nursing schedule dated [DATE] revealed CNA A, RN B, and Medication Aide C (MA C) worked Resident #16's hall from 07:00 AM to 07:00 PM. During an interview on [DATE] at 11:00 AM with CNA A stated he has worked at the facility since [DATE]. CNA A stated Resident #16 was cool - she was calm, nice, and she liked coffee and hot tea .she could not walk, she was bed bound, she was recovering from a fractured leg, and she lived on the second floor. CNA A stated he worked Thursday [DATE] from 07:00 AM to 07:00 PM, it was a normal day . at dinner time, around 06:00 PM, MA C and I helped serve residents their meals .I did not serve Resident #16 . I was in the room across from Resident #16 .I heard a call light and came out and saw (Resident #16's) call light, I went in, and I saw Resident #16 seated in her wheelchair with a distressed look on her face, gasping for air. I called and yelled for RN B, I swept Resident #16's mouth and discovered some food, it looked like bread. RN B arrived; we repositioned Resident #16 on the floor. RN B called out for help, and we continued to sweep Resident #16's mouth, we were finding pieces of food, bread .MA C came in the room and RN B told her to bring the crash cart (a cart supplied with CPR supplies) and call 911, we began CPR with RN B performing chest compressions. MA C returned with the crash cart, and we began using the AED (automatic external defibrillator) and the suction machine to suck out food from Resident #16's mouth / throat; we continued CPR with RN B doing chest compressions and I provided rescue breathing with the bag, we took turns about 2x each when EMS arrived and took over. During an interview on [DATE] at 11:15 AM MA C stated she has worked at the facility [AGE] years. MA C stated Resident #16 was nice and sweet .she took her pills whole .she had a wheelchair. MA C stated she served residents their meals. MA C stated the kitchen prepared and delivered the residents' meals to the unit in a meal cart. MA C stated on [DATE], she retrieved Resident #16's dinner from the cart and served Resident #16 her dinner, which consisted of a ham sandwich and then proceeded to serve other residents. MA C stated Resident #16 ate in her room. MA C stated she was alerted to Resident #16's room where she saw RN B and CNA A providing CPR to Resident #16 on the floor. MA C stated RN B called for MA C to bring the crash cart and call 911. MA C stated she returned with the crash cart. MA C stated she called 911 on her cell phone at 06:37 PM, and then made the path clear for EMS. MA C stated she went to the front door to guide EMS to Resident #16 once they arrived. During an interview on [DATE] at 01:27 PM RN B stated Resident #16 would prefer to eat in her room. RN B stated Resident #16 had a need for a mechanical soft diet but would often refuse her diet texture, for example she would eat bacon for breakfast. RN B stated on [DATE] at dinner time, around 06:00 PM, she was assisting and providing care for another Resident. RN B stated she had not reviewed residents' dinner meal trays for safety and CNA A and MA C were serving residents their dinner meals. RN B stated had she reviewed Resident #16's sandwich she may not have seen the ham was sliced and not ground per mechanical soft diet texture protocol due to the sandwiches are wrapped and she did not routinely unwrap sandwiches. RN B stated she believed the kitchen prepared sandwiches for mechanical soft diet textures with ground lunch meats, like ham salad. RN B stated she was assisting another Resident in their room when she heard CNA A calling for her in Resident #16's room. RN B stated she immediately went to the room and discovered CNA A and Resident #16 in her wheelchair. Resident #16 was not breathing and was distressed. RN B stated she and CNA A began sweeping Resident #16's mouth and removed food debris. RN B stated she called out for help and MA C arrived, I told her to bring the crash cart and call 911. RN B stated MA C returned with the crash cart and she and CNA A used the suction machine and continued to remove food debris. RN B stated Resident #16 became unresponsive without a pulse and breath. RN B stated she and CNA A repositioned Resident #16 to the floor and began CPR with the use of the AED. RN B stated she and CNA A took turns and turned over CPR to the EMS paramedics when they arrived. A record review of Resident #16's hospital history and physical record, dated [DATE] revealed Resident #16 was admitted to the emergency room at the local hospital at 09:11 PM, Patient admitted : [DATE] at 21:11 (09:11 PM) BIBEMS (brought in by EMS), from nursing home after choking episode and cardiopulmonary arrest. EMS obtained ROSC (return of spontaneous circulation) after 20 minutes of CPR / ACLS (cardiopulmonary resuscitation / advanced cardiac life support). Difficult airway with lots of debris thus LMA (Laryngeal Mask Airway, a tube inserted down the throat to facilitate the airway) used until definitive airway obtained at (hospital) emergency room by emergency room physician using [NAME] ([NAME], a guide for an airway tube to be inserted). Patient hypotensive (very low blood pressure) .Reportedly mental status notable for repetitive twitching motion. During my exam flaccid after RSI (rapid sequence induction) drugs with pupils 4mm appeared fixed. Significantly hypoxic (severe low blood oxygen) with bilateral multifocal infiltrates (both the left and the right have widespread debris) on x-ray. Requiring aggressive pulmonary toilet by respiratory therapist (suctioning the airway to remove debris and mucus) irrigation and suction frequently currently requiring 100% oxygen) A record review of Resident #16's hospital Discharge Summary record, dated [DATE] revealed Resident #16's physician pronounced Resident #16's death at 11:06 PM, During nursing care assessment (of) patient rhythm converted to asystole (also known as flatline, a state of standstill for the heart) and patient noted pulseless. CPR per ACLS initiated and code blue called .discussion initiated with (family representative) in waiting room current status and plan for proceeding. Informed suspicion for anoxic brain injury (severe brain cell death resulting in permanent cognition loss) given information that patient (was) found down arrested (unresponsive) and ROSC after 20 minutes (brain injury can begin after 4 minutes) .(family member) was offered and requested to witness active resuscitation efforts and at that time surrogate decision was made by (family member) to terminate efforts .time of death called at 23:06 (11:06 PM) . preliminary cause of death: choking / severe aspiration (when food and or drink are sucked into the airway and lungs). During an interview on [DATE] at 11:38 AM the DON stated she believed the ham sandwich with thinly sliced ham was compatible for residents who required mechanical soft diets. The DON stated the plan was developed by the RD to support residents with the need for mechanical soft diets. During an interview on [DATE] at 01:30 PM the RD stated she had reviewed and approved the facility's alternative menu spreads to include the compatibility of a ham sandwich with thinly sliced ham with the needs of residents who required mechanical soft diets. The RD stated her research and use of professional standard resources supported the compatibility of a ham sandwich with thinly sliced ham with the needs of residents who required mechanical soft diets. The RD stated the rationale was to improve residents' compliance with their diet textures and thereby improve nutritional intake and over all mitigate weight loss and malnutrition. During an interview on [DATE] at 05:00 PM the SLP stated Resident #16 had a difficult swallow response due to the muscle atop of her throat was not functioning well. The muscle referred to as the CP was weak and would allow food to come back up reflux and could enter the airway. The SLP referred to the situation as a CP bar and was complicated by Resident #16's muscular dystrophy and history of strokes. The SLP stated she had evaluated Resident #16 and had recommended Resident #16 to be served a mechanical soft diet specific for ground meats. The SLP stated her definition of mechanical soft would be like the International Dysphagia Diet Standardization Initiative's level 5. The SLP stated her expectation for mechanical soft would include foods which were soft and moist, with no liquid leaking / dripping from the food, where biting is not required, minimal chewing was required, lumps of 4mm in size, lumps can be mashed with the tongue, food could be easily mashed with just a little pressure from a fork, food should be able to be scooped onto a fork, with no liquid dripping and no crumbles falling off the fork. The SLP stated she did not believe a ham sandwich met those requirements. The SLP stated she believed the meats should be ground for a mechanical soft diet and stated a ham sandwich could be served as a ham salad sandwich for residents who required a mechanical soft diet. The SLP stated Resident #16's risk for not receiving mechanical soft foods was choking and aspiration. During an interview on [DATE] at 05:50 PM the Administrator stated she believed the ham sandwich with thinly sliced ham was appropriate for residents who required mechanical soft diets. The Administrator stated she stated she had confidence in the professional guidance from the RD was to support residents with a mechanical soft diet with the lunchmeat sandwiches made with thinly sliced meat. During an interview on [DATE] at 06:10 PM NP L stated she had conferenced with the Medical Director and at this time could not offer opinions on the compatibility for a ham sandwich as prepared and served by the facility for the remaining residents at the facility who were ordered a mechanical soft diet. During an interview on [DATE] at 07:04 PM NP L stated she was the NP for Resident #16. NP L stated she and the Medical Director reviewed Resident #16's medical record and believed a ham sandwich with thinly shaved ham could have been safe for Resident #16 to consume per her mechanical soft diet. Record review of policies for Resident Food Services with the subject Diet Orders and Other Resident Information (policy #C203, date issued- ,d+[DATE]; revised date ,d+[DATE]) on [DATE] at 4:26PM revealed the policy stated: Diet orders should be determined with the resident or responsible party and in accordance with his/her informed choices, goals, and preferences. The responsible physician or designee or qualified dietician/other clinically qualified nutrition professional per state regulations, must order the diet in writing. The community may delegate the task of writing diet orders to a Registered Dietician who is acting within the scope of practice as defined by state law and is under the supervision of a physician. Nursing is responsible for communicating all nutrition related information to the Food and Nutrition department per community protocol. A record review of the International Dysphagia Diet Standardization Initiative's website, https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/5_Minced_Moist_Adults_consumer_handout_30Jan2019.pdf Accessed [DATE], Revealed, Minced and Moist, level 5, minced and moist food for adults; what is this food texture level? Level 5 - minced and moist foods: Soft and moist, but with no liquid leaking / dripping from the food. Biting is not required. minimal chewing required. lumps of 4mm in size. food can be easily managed with just a little pressure from a fork. should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork. Why is this food texture level used for adults? Level 5 minced and moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food but are not able to chew it down into little pieces that are safe to swallow. Minced and moist foods only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It is important that minced and moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or fork . Examples of level 5 minced and moist foods for adults, meat served finely minced or chopped to 4mm lump size served in a thick smooth, non-pouring sauce or gravy .no regular dry bread due to high choking risk! Missing The facility's Administrator was notified and presented with a IJ template on [DATE] at 07:00 PM, a Plan of Removal was requested from the facility. The following Plan of Removal submitted by the facility was accepted on [DATE]. Plan of Removal IJ Immediacy Removal Plan F 805 Facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs [DATE]. 1. All thin sliced meat options designated for mechanical soft diets were removed from all SNF units, (Unit 1), (unit 2), and (memory care). [DATE] 2. Dietary Policy, Dietary Spread Sheets, and Dietary Menus were revised to show that all thin sliced meat options designated for Mechanical Soft Diets were removed and appropriate alternates noted. [DATE] 3. All Staff working in facility were in-serviced by noon on [DATE] on Policy #C203 and #C219 , Titled Diet Orders and Other Resident Information and Snacks. The changes removed sandwiches with thinly sliced meats from all documents. In addition, Nursing Unit Stock Item List was updated, Seasonal Menu and Spreadsheets were updated to also reflect removal of thinly sliced meat as an option for mechanical soft diets. These policies will be available for reference by staff located in the Food Service Office, the Facility shared drive and presented as a visual for in-services. 4. Dietary Manager or Dietary Designees will monitor kitchen and all unit refrigerators routinely to ensure that appropriate sandwich options are available. [DATE] The Dietary Manager or Designee will be assigned to monitor tray line and sign off as to compliance of correct texture as ordered each meal for 14 days, then each meal twice a week for two weeks then three meal services once a week for 3 months. Administrator or Designee will follow up with meal tray monitor/audit twice a week for 3 months, at random meals to ensure tray line accuracy. Results to be reported to QAPI. 5. Nurse Practitioner and Medical Director were advised by Administrator and in agreement with plan. [DATE]. Diet modifications orders will continue to be reviewed by nurse and translated to MD for approval. Diet modifications will be followed per SLP recommendations as approved by the MD. RD is notified via diet communication forms initiated by nursing staff once orders are confirmed. As with any orders or change in condition or treatment, will be further addressed in IDT mtg with DON, RD, Rehab Manager and other disciplines as appropriate. Diet spreadsheets [DATE] will be changed to ensure next available meal is accurately identified with up-to-date texture modifications for staff to follow. Care Plans will be updated per regulations. DON or designee will audit diet orders and associated care plans once every two weeks for three months to ensure compliance. Results will be reported to QAPI. An audit was conducted [DATE] by Dietary Manager and nursing for all residents with mechanical diet orders and no other residents were found to have been affected by this deficient practice. All thin sliced meat options previously designated for mechanical soft diets were removed from all SNF units. Diet modifications orders will continue to be reviewed by nurse and translated to MD for approval. Diet modifications will be followed per SLP recommendations as approved by the MD. RD is notified via diet communication forms initiated by nursing staff once orders are confirmed. DON or designee will audit diet orders and associated care plans once every two weeks for three months to ensure communication between RD and SLP is appropriate and timely. Results will be reported to QAPI Plan of Removal Verification IJ Immediacy Removal Plan F 805 Facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs [DATE]. 1.All thin sliced meat options designated for mechanical soft diets were removed from all SNF units, (unit 1), (unit 2), and (memory care). [DATE] During observation of SNF Units- (1), (secured unit), (2), on [DATE] at 04:40 PM, revealed all deli meat sandwiches, peanut butter and jelly sandwiches and peanut butter and jelly on crackers were removed from the refrigerators and replaced with egg salad sandwiches as a sandwich alternative for residents on mechanical soft diets. A list of approved alternative foods was also posted on the units. 2. Dietary Policy, Dietary Spread Sheets, and Dietary Menus were revised to show that all thin sliced meat options designated for Mechanical Soft Diets were removed and appropriate alternates noted. [DATE] During observation [DATE] at 4:25 PM, a cork board had an Alternate Menu with deli meats, peanut butter and jelly sandwiches, and peanut butter and jelly crackers removed as an alternate for residents on mechanical soft diets and was approved by the RD. Review of the Alternate Menu Spreads revealed modified foods for all diets with mechanical soft foods with what foods were approved and what foods that were not approved. Seasonal Menus and Spreadsheet Review and Approval was also approved by the RD. 3. All Staff working in facility were in-serviced by noon on [DATE] on Policy #C203 and #C219, Titled Diet Orders and Other Resident Information and Snacks. The changes removed sandwiches with thinly sliced meats from all documents. In addition, Nursing Unit Stock Item List was updated, Seasonal Menu and Spreadsheets were updated to also reflect removal of thinly sliced meat as an option for mechanical soft diets. These policies will be available for reference by staff located in the Food Service Office, the Facility shared drive and presented as a visual for in-services. During an interview on [DATE] at 01:05 PM Med Aide F stated she was in-serviced on receiving the diets that were ordered for the residents. She stated if it was a new resident what are the orders for the resident for example with medications, she would find out if the resident would get pudding or applesauce if they receive medications that are crushed. She stated as far as she knew, all the sliced meats were removed off the units. She stated she received the in-service in the morning yesterday. She stated if she saw someone with an incorrect diet, she would ask the resident if she could remove the plate and take it to the nurse. She stated the diet would be on the meal slip that would identify their diets . During an interview on [DATE] at 01:15 PM CNA M (unit 1) stated he had been in-serviced on correct residents' diets yesterday [DATE]. He stated regular diets have no change to the texture and mechanical diets are ground meats. He stated if he saw someone with the incorrect diet, he would explain it to the resident about the diet not being safe and inform the nurse. He stated he would remove the tray from the table. He stated all sliced lunch meats have been removed from the unit. He stated an alternative would be soups, chicken salad, or baked potato/sweet potato. He stated the diet should be stated on the meal ticket. Sometimes with new residents, the ticket may not be printed, and he would ask the nurse what the diet order was for the newly admitted resident. During an interview on [DATE] at 01:23 PM CNA X (unit 1- 35years ) stated she had the in-service about mechanical diets. She stated the sandwiches were removed from the unit. She stated she would look at the meal ticket or look at the resident's chart under dietary . She stated if someone had the wrong diet, she would not allow the resident to have the tray and explain why and then she would call the kitchen and notify the nurse. She stated other options would be egg salad, chicken, tuna, and ham salad- all soft and ground. She stated it was common sense to get something equal. During an interview on [DATE] at 01:52 PM LVN V (unit 2- 2 years ) stated she had the in-service today before the start of her shift. She stated mechanical soft is moist ground meat, easy to chew. Egg salad, chicken salad, tuna salad had been brought to the unit and all other lunchmeats, peanut butter and jelly sandwiches and peanut butter and jelly crackers have been removed. She stated if someone received a wrong diet texture, she would immediately figure out what texture the resident should receive and switch out for the correct tray because they have extra pureed, mechanical soft and regular trays. If not, she would call the kitchen. She stated the process was, staff is notified that trays are delivered, and the nurses check the trays before they are handed to the aides that assist with passing out trays to the residents. She stated if someone stated they wanted to eat a regular sandwich she would not give it because of the dietary restriction. She stated she would educate them on the importance of why they are on a specific diet. If they say it was their right, she would offer them an alternative that is within their diet restriction. If that was not effective, she stated she would call the physician. During an interview on [DATE] at 02:37 PM CNA G (memory care PRN 1 year ) stated the trays arrive, they look at tickets, check the food and check the diet and make sure they have what they are supposed to have, along with the nurse on the unit checking as well. She stated if she saw a tray with the wrong food or texture, she would inform the nurse. She stated she had an in-service yesterday about the sandwiches on the unit that they were no longer using lunchmeat only chicken, tuna, and egg salad as substitutes. She stated the sandwiches had been removed. She stated they had an in-service today about respect and dignity. She stated a mechanical soft meal, the meat would be ground to look like hamburger. She stated for some ground meat, they would add a gravy. During an interview on [DATE] at 02:42 PM CNA/MED AIDE Z (Unit 2 and Training) stated she gave the in-service on the mechanical soft foods. She stated the crackers with peanut butter and lunchmeat sandwiches were removed from the units. She stated the alternatives were egg salad, tuna, chicken, and ham salad. She stated she would inform the nurse if the resident refused to accept the meat texture recommended for safety. She stated mechanical is chopped up or soft foods. She stated if the meat is chopped but dry, gravy would be added to make the meat moist. During an interview on [DATE] at 03:07 PM CNA R (Unit 2- 6 months ) stated she had the in-service for sandwiches yesterday and the other in-service was abuse and neglect . She stated the sandwiches were to be used for alternatives for residents with mechanical soft diets for residents . She stated she would check the meal against the ticket and alert the nurse if the tray was incorrect. She stated trays are passed out by looking at the ticket, making sure diet is correct for the resident and making sure all the food on the ticket matches. She stated the nurse checks as well. She stated the lunchmeat sandwiches had been removed from the unit and replaced with chicken and tuna salad sandwiches. During an interview on [DATE] at 03:12 PM CNA C (Unit 1- 16yrs ) stated she had the in-service about no more peanut butter crackers, instead tuna salad sandwiches yesterday. Puree is like baby food consistency, and mechanical soft is ground with gravy. She stated when food trays are passed, they make sure the trays are accurate according to the resident's diet. She stated to make sure the resident's diet is accurate on the tray and meal ticket, she would look in the chart and ask the nurse if she was not sure. She stated she would let the nurse know immediately if a tray was incorrect and call the kitchen. She stated if she saw someone with the wrong tray in front of them, she would inform the resident that the tray was incorrect and switch it with the correct tray. She said she would allow the resident to keep what is soft to eat like a pudding and let the nurse know as well. She stated she was told the sandwiches were removed from the unit, but she had not checked yet. During an interview on [DATE] at 03:20 PM CNA Q (floats to other units) stated she had the in-service about peanut butter crackers and no deli meat sandwiches and they were substituting egg salad and tuna salad sandwiches yesterday. She stated mechanical soft includes ground meats, sometimes fruit is ground, and sometimes the residents would get gelatin instead of a salad. She stated the deli sandwiches had been removed and replaced with egg and tuna sandwiches. She stated if she saw someone with the wrong tray, she would not give it to the resident and inform the nurse. She stated the nurse would look at the trays as well. She stated the nurse checks the trays before they pass them to the residents. She stated she would tell the nurse if a resident insisted on having a diet outside of the order or recommenda [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure, based on the comprehensive assessment, the facility must ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #2) reviewed for pressure ulcers. Resident #2 did not receive a wound care assessment and consult ordered on [DATE] for two open skin areas on bilateral buttocks and one open skin area to the coccyx as noted in a telephone order until 7/23/20. The findings included: Record review of Resident #2's Face Sheet, dated 8/17/20, revealed Resident #2 was admitted on [DATE] and discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Care Plan revealed: problem onset of 1/13/20 has a short-term memory deficit and time disorientation due to dementia evidenced by a BIMS score of 5. problem onset of 6/3/20 has an open lesion (non-pressure area) to rectal area, which included the following interventions: reposition every two hours, wound care as ordered by a physician, weekly evaluation of wound healing, daily observation of skin with routine care, full skin evaluation with bath or shower, monitor changes in skin status for worsening of skin area. problem onset of 7/20/20 required assistance of two for transfers and required assistance with toileting. problem onset on 7/24/20, revealed Resident #2 had a stage 3 pressure ulcer (Full thickness tissue loss and subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. Areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.) to the sacrum, which included the following interventions: encourage Resident #2 to shift his weight while sitting up in the wheelchair, wound care as ordered by a physician, two-person assist with transfers, encourage good nutritional intakes, weekly evaluation of wound healing, daily observation of skin with routine care, full skin evaluation with bath or shower, monitor changes in skin status for worsening of skin area, refer Resident #2 to the Wound Care Specialist or Wound Care Clinic for evaluation. problem onset on 7/26/20, revealed scheduled care tasks of weekly skin assessments, Braden Scale, and Weekly Pain Assessment by the nurse. Record review of Resident #2's medical chart revealed telephone orders for wound care ordered by Resident #2's Nurse Practitioner; dated 6/3/20, to evaluate and treat Resident # 2 due to a rectal ulcer. dated 6/27/20 for a wound care consult to evaluate and treat due to two open areas on bilateral buttocks and one open area to the coccyx. dated 7/23/20, described wound care for Resident #2's sacral wound as Clean Wound with NS (non-saline) or wound cleaner, pat dry, apply nickel thick layer of Santyl pack (Santyl Ointment uniquely and actively debrides by cleaving necrotic tissue at seven specific sites along the denatured collagen molecule) with Hydra foam (Designed to maintain a moist wound environment, this dressing supports wound healing and autolytic debridement) plus cover with Adhesive foam dressing every Tuesday, Thursday, Saturday, and as needed if soiled or dressing dislodged. dated 7/31/20, Clarification: Sacral Wound cleanse wound with NS pat dry apply nickel thick layer of Santyl to wound base pack with HF blue salve with Excel SAP silicone border dressing (Superabsorbent (SAP) core fiber pad quickly absorbs, gels to retain blood and exudate from the wound or surgical site, then perforated silicone adhesive contact surface to secure the dressing and prevent trauma and a protective film top.) every Tuesday, Thursday, and Saturday. Record review of Resident #2's Wound Assessments revealed on: 6/2/20 and 6/9/20 revealed he had a skin tear on the rear left forearm. 7/23/20 for a pressure ulcer on his sacrum, which revealed it was a new wound that was identified on 7/23/20, stage 3 with no infection or pain with wound/treatment and measurements of 2.5 cm length, 1 cm width, and 1 cm depth. 7/30/20 did not indicate any changes. Record review of Resident #2's Medical Record revealed Resident #2 only had two CNA shower skin assessments completed and turned into the nurse (missing approximately 11); one dated 7/28/20 revealed he had an ulcer near his coccyx and on 7/30/20 he had an open area on his scrotum, L buttock, and a stage II (Loss of dermis presenting as a shallow open ulcer with a red- pink wound bed or open/ruptured serum-filled blister. Full thickness ulcer) wound on his sacrum. Record review of Resident #2's History and Physical from the hospital physician, dated 8/13/20, revealed while at the nursing facility, Resident #2 was noted to have an elevated white blood cell count of 20.8 and then, Resident #2 was then sent to the emergency room and was found to have a stage IV sacral decubitus ulcer. Record review of a Photographic Wound Assessment and Documentation, dated 8/13/20, from the hospital, revealed Resident #2's wound was an unstageable sacrum wound with large, serosanguinous, malodorous exudate with 100% eschar with no wound pain. The peri wound was macerated with the length, width, and depth being 4.8 x 2.5 x 3 cm, respectively, an area of 8.9 cm, and volume of 267.3 prior to debridement. Record review of a facility binder titled, IDT 2020 revealed there were only IDT Attendance Sign in sheets and Resident Forms through 5/20/20. Record review of a facility binder titled, The Willows 24-Hour Book revealed Attention Nurses: All incident reports, behaviors, med errors, deaths, admissions, hospital transports, or any change in condition must be reported to the unit Manager. Revealed 24-hour Report/Change in Condition Report and for each day since 6/22/20 the communication sheets for each day included columns for written notes regarding Admits/Readmits/Discharges, Antibiotics, Medicare/Insurance, Change in Condition, and Residents and day and night remarks. The 24-Hour Report/Change in Condition Reports from 6/26/20 through 7/320 revealed Resident #2's wounds were not noted. During an interview on 8/19/20 at 1:32 pm, the Wound Care Nurse stated he created a wound module, the first time he established the Resident #2's wound, on 7/23/20, and it was a stage 3, borderline stage 4, on the sacrum. The Wound Care Nurse stated he had a difficult time believing that the staff there were negligent enough to let this wound become as well established as it was on Resident #2. The Wound Care Nurse stated the wound presented similarly to a rapidly progressing Kennedy-like wound, however, the resident was not end of life status, has maintained his weight in the past 6 months with good fluid and food intakes. He stated that the Resident #2 liked to sit in a recliner often. The wound did not improve since 7/23/20. During an interview on 8/19/20 at 1:49 pm, Charge Nurse A stated Resident #2 required a lot of care and Resident #2 had a wound to his sacrum that was bad. Charge Nurse B stated she first knew about the wound on 7/23/20. Charge Nurse B first saw the wound on 8/4/20, it was an open wound to the coccyx area with some necrotic tissue. During an interview on 8/19/20 at 2:22 pm Charge, Nurse A stated she did not see an order from the MD in the chart on 8/19/20 at 2:22 pm, during the interview, but there was an order for [REDACTED]. During an interview on 8/19/20 at 2:08 pm, CNA C stated CNA C believed the sore on Resident #2's coccyx started developing about 1.5 month ago that presented as a white patch of skin. CNA C stated a couple of days later Resident #2's coccyx area started to scab, and she notified the nurse on duty and stated they were going to put Triad cream on it. The scab started to get bigger and she notified the nurse on 7/27/20. CNA C saw Resident #2's coccyx area while changing his brief. CNA C stated later that Thursday or Friday, a CNA, during report, told her Resident #2's coccyx area had opened and was oozing fluid. CNA C stated three days before he was transferred out to the hospital the wound began to smell. CNA C stated she notified the Charge Nurse A of the smell . During an interview on 8/19/20 at 3:15 pm, CNA D stated she noticed Resident #2's coccyx wound about 1.5 months ago and it looked like a stage 3, but at that point the Wound Care Nurse was already providing wound care. Resident #2 was eating well, and CNA D would assist him with his meals and drinking fluids. CNA D first saw the wound during a shower. CNA D stated when the CNAs showered Resident #2, they do skin assessments on a piece of paper and then turn it into the nurses. CNA D noticed some redness on Resident #2's bottom during the showers that reported it to the nurse. However, there was a period of about 3-4 weeks where she did not work with him and after that point is when she learned the wound had worsened. During an interview on 8/19/20 at 3:35 pm, Charge Nurse B stated Resident #2 developed a small stage II to peri-area near his rectum about 2 months ago. Charge Nurse A stated Resident #2 developed another area on his sacrum about a month ago and it had a flap and looked like a stage I, but when she pulled on the flap, it was red and looked like a stage II. She stated Resident #2 was sent to the hospital on [DATE] due to abnormal labs. During an interview on 8/20/20 at 3:00 pm, the Wound Care Nurse stated he did recall assessing Resident #2 around 6/3/20 and the rectal area looked like a rectal excoriation, however, he did not document his assessment because it wasn't a pressure ulcer. He stated he does not remember seeing the 6/27/20 order at all and did not provide a wound assessment at that time. Wound Care Nurse stated Resident # 2 was not seen by Wound Care Specialist. He did not know about an open area on his scrotum. The Wound Care Nurse stated a wound must go through the stages from partial thickness to full thickness. In general, the stages of a wound in the buttock area like Resident #2's wound first involved a reddened localized area around each ischium and sacrum. As it started to turn red, they started using barrier cream for Resident #2's wound. A stage II is when the skin starts to break, like a shallow blister. Then, from there the wound started breaking away and the wound started eroding, which leads to partial thickness into the muscle layer and eschar and tissue slough. At this point the wound would be considered a stage III. Resident #2 had slough, partial thickness, and eschar. The Wound Care Nurse doesn't know when the wound started, and he has a hard time believing the wound developed in three weeks. He stated he first notified the NP of the wounds on 7/23/20. Resident #2 had several risk factors for skin problems, including the following, he slept in a recliner chair in the ALF leaned over and preferred the wheelchair. The Wound Care Nurse stated Resident #2 was sent to the hospital on [DATE] due to abnormal labs and was found to have a wound infection. During an interview on 8/21/20 at 11:25 am, the Wound Care Specialist, who was currently treating Resident #2 in the hospital, stated the facility will consult a Wound Specialist if the resident needed more specialized wound care. He stated on 8/13/20, while being treated in the hospital, Resident #2 had an unstageable coccyx wound with a necrotic wound base, heavy drainage, however, the peri-wound area was healthy. He wishes the facility had consulted a Wound Specialist for Resident #2 earlier. Resident #2 had a wound infection, however, they facility was regularly ordering labs and sent the resident to the hospital when his labs indicated an infection. During an interview on 8/21/20 at 11:40 am, the Wound Care Nurse stated he did not request a consult with the Wound Care Specialist because the Wound Care Specialist had been out of the facility and only doing telehealth due to COVID-19. He stated he probably should have consulted the Wound Care Specialist. During an interview on 8/21/20 at 2:27 pm, the DON confirmed the wound care assessment ordered on [DATE] was not completed. The DON stated she was not sure how the drop-in communication occurred. The DON believed the breakdown happened because the unit managers were supposed to check the 24-hour reports every day and discuss at the IDT meetings, but Resident #2's coccyx wound was not discussed with anyone. She does not know why the wound care nurse did not receive the wound care order. The other problem was the wound was found on a Friday evening and communication got dropped. During an interview on 9/9/20 at 12:50 pm the DON stated IDT meetings were supposed to be every other Wednesday, but they have not been able to have IDT meetings in about 6 weeks. During an interview with the DON on 9/9/20 at 2:30 pm the DON stated there was a lack of systematic communication, which led to them failing to see the order for Resident #2 on 6/27/20 for a wound assessment. The DON stated there was a systemic lack of communication and follow-up on multiple levels. The DON stated whoever wrote the order was responsible for checking up on it. The Charge Nurses should have placed the new order on the 24-hour report and the Unit Managers were responsible for going through their 24-hour reports. The DON stated the Weekend Wound Care Nurse signed off on Resident #2's 6/27/20 telephone order for a wound care consult and the Weekend Wound Care Nurse knew about Resident #2's wound and The Weekend Wound Care Nurse was treating the wound, but the DON stated she did not find any documentation showing that. The DON stated the Wound Care Nurse reported Resident #2's wound to her on 7/23/20 and she asked why the wound was only just found and identified at that time. The DON stated the daily skin checks completed by the CNAs during resident showers were not being completed. The DON asked the Charge Nurses about the weekly skin assessments and learned that the Charge Nurses were not doing a visual check of the residents and were just writing in the EMR the existing wound information when prompted. During an interview on 9/9/200 at 1:40 pm, Nursing Manager K stated during IDT meetings they discussed skilled care, antibiotics, falls, and changes in condition. The Unit Mangers were responsible for making sure the Follow-ups, which were Changes in Condition and monitoring for 72 hours every shift, were documented in the EMR under Nursing Notes and during morning meetings held every morning consistently. They discussed census, orders, MDS reviews the skilled patients progress and needs, nursing stays, orders, incidents and accidents, falls, antibiotics, skin issues, which should have been on the 24-hour report. The copy of the order should have been given to the wound nurse and pharmacy. The original was sent to medical records. She stated the Unit Managers reconciled orders during morning meetings. During an interview on 9/9/20 at 2:55 pm, the DON stated they have not had an IDT meeting since 5/20/20. During an interview on 9/10/20 at 2:05 pm, Charge Nurse A stated the nursing skin assessments were prompted by the system they use in the DMR, and they must type whether the resident's skin was intact or not intact. She stated as a Unit Manager she did not monitor the nursing skin assessments completed by the Charge Nurses. Charge Nurse A stated the nursing skin assessments completed by the Charge Nurses should have been done weekly. Charge Nurse A stated the nurses would have only known a resident had a wound if the Wound Care Nurse was treating it. Record review of a facility policy titled, Pressure Injury and Prevention Management, policy number 4.01.01, date issued 4/17/19, revealed the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying factors; monitoring the impact of the interventions and modifying the interventions as appropriate.

Based on observations, interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for ensure that residents were free from neglect and received adequate supervision and assistance to prevent accidents for 3 of 14 residents (#10, 13 and 14) whose care was being reviewed in that: 1. The Administrator and DON failed to supervise staff on the memory unit to ensure Residents #10, 13 and 14 received supervision to prevent injuries. Resident # 9 fell and sustained multiple lacerations. Resident #10 wandered out of the building, fell died from her injuries and heat stroke. Resident # 13 wandered out of the memory unit during a heat wave of 100 degrees and Resident #14 wandered out of the memory unit and sustained a skin tear from a jagged edge on the metal door when attempting to reenter the building. 2. The Administrator and DON failed to in-service the nursing staff on the memory unit to increase supervision of residents wandering out of the unit into the courtyards during a heat wave of 100 plus degrees. Residents were being monitored by camera from the nurses' station and the camera screens were too blurry to provide good vision. 3. The Administrator and DON failed to implement a system that ensured wandering residents on the memory unit were escorted when leaving the unit during extremely hot weather. Staff were not in-serviced to frequently monitor the locations residents on the memory unit. These failures resulted in an Immediate Jeopardy (IJ) situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated until the secure unit was made safe and the entire staff was in-serviced. These deficient practices could affect 33 residents who were ambulatory and able to wander through the exit doors of the memory unit into the outside gardens and who were at risk for falls, wandering and elopement due to cognitive deficits, lack of coordination, and unsteady gait and could result in deterioration in health, heat stroke and death. The findings were: 1. Review of the facility administrator's personnel file revealed the administrator was hired on [DATE] to assure the provision of the best available quality of care for facility residents. The Quality Assessment and Assurance Program encouraged the administration to objectively and systematically monitor and evaluate the quality and appropriateness of resident care on an ongoing basis; to pursue opportunities to improve resident care; to identify problems and to integrate the ongoing operational activities of the medical and management team. Review of the facility investigation report dated [DATE] revealed that Resident #10 was found outside of the memory care unit on the ground in the enclosed courtyard on [DATE] at approximately 17:15 (5:15 p.m.) in an area that could not be seen by a camera located in the courtyard. The resident was lying in the dirt (rocks), incoherent, twitching, shaking and very warm. The investigation report also revealed that Resident #10 had [MEDICAL CONDITION] her feet and legs from the heat. The resident's internal body temperature was 107.2 degrees. The resident was last seen by the staff between 3:,[DATE]:30 p.m. in the dining room. She got out into the courtyard. She was found at 5:15 p.m. when the staff couldn't find her for dinner. The resident sustained [REDACTED]. Review of a quality assurance meeting agenda conducted on 6//,[DATE] did not address the circumstances of Resident #10's fall and death from heat stroke and no plans were recommended to ensure a similar incident did not re-occur. During observations on [DATE], [DATE] and [DATE], staff were observed making 15-minute checks of the outside areas where residents wandered in and out of the building. The outside temperatures according to the local weather reports was 95 to 100 degrees Fahrenheit. Residents were not prevented from exiting the building and there was no formalized system in place to inform the staff of the special needs of residents. The monitoring system of residents from the nurses' station was inadequate due to the foggy screens, which prevented residents from being identified. During an interview on [DATE] at 6:40 p.m., the Administrator reported that the based on the concerns for safety in the memory unit reported by the surveyor, the facility planned to install a second camera on the west outside courtyard, monitor the exit doors by posting staff to prevent residents from exiting, install magnetic locks (maglocks) to each exit door (2) and audit care plans of residents on the unit to ensure care needs were addressed. Review of a publication dated 2009 and entitled Keeping the Elderly Safe during Summer Heat Waves, recommended that nursing homes go on alert when temperatures rise, and seniors are particularly susceptible to serious health complications from hot weather, including heat exhaustion, heatstroke, sunburns and dehydration. Many seniors are on medications such as diuretics that make them more prone to the burning rays of the sun. Just a short period of time in the sun can cause some major health complications. Heatstroke commonly affects individuals who are debilitated or fatigued. Symptoms include dizziness, weakness, nausea, rapid pulse and a body temperature of more than 102 degrees. Review of a publication dated 2012 entitled Dangers that heat waves pose to seniors, revealed that temperature control centers in the brain become less sensitive with age and may therefore not initiate the correct cooling mechanisms when the body becomes overheated. 2. Review of the job description of the Director of Nurses (DON) issued on [DATE] revealed that the DON reported to the Administrator and that the primary responsibility was to ensure the provision of quality of nursing care on a 24-hour basis to the resident .in accordance with Federal, State, Local standards and regulation. The DON develops nursing service objectives, policies and procedures and directs the implementation of these objectives. The DON analyzes and evaluates overall resident care programs; confers with managers and staff concerning problems of resident care and ensures that residents are free from abuse, mistreatment and neglect. The DON also assists the Safety Officer in developing and implementing safety standards for the Nursing Department; and assists the Administrator in the development and implementation of the Quality Assurance and Performance Improvement (QAPI) Program. During an interview on [DATE]at 3:00 p.m., the DON was asked if the incident on [DATE] with Resident #10 was discussed at the [DATE] QAPI meeting and if plans had been made to prevent further incidents. The DON reported that the incident was mentioned but was not discussed in detail. No plans were developed to prevent future incidents, except that the staff was required to go outside and look for the presence of residents in the 2 yards every 15 minutes. Review of the QAPI annual agenda dated [DATE] listed falls to be discussed in (MONTH) and August. Review of the QAPI policy dated [DATE] and signed by the DON, Medical Director and Administrator revealed that the policy was to be updated annually or more often when revision was deemed appropriate by the Quality Assurance Committee. Review of the sign-in sheet dated [DATE] listed 19 signatures which included the Administrator, DON, Director of Physical Environment and Medical Director. During the exit conference on [DATE] at approximately 5:00 p.m., the DON was asked the question: How long had the facility planned to have the staff continue 15-minute checks of the outside areas of the east and west porches and backyard. The DON responded: Until we came up with a better idea. 3. Review of Resident #10's admission face sheet dated [DATE] revealed the [AGE] year old resident was admitted on [DATE] and readmitted on [DATE] with a medical history of [REDACTED]. The resident resided in the Memory/Secure Unit and was discharged on [DATE] to a hospital after an incident. Review of a quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3, indicating severe cognitive deficit, which included inattention and disorganized thinking. Resident #10 was also assessed requiring extensive assistance with transfers, ambulation, dressing, bathing and hygiene and was incontinent of bowel and bladder. The resident weighed 114 pounds and was 59 inches tall. Review of a care plan dated [DATE] revealed the resident tended to get out of her wheelchair and walk away unattended. One of the interventions was to place her in an area where frequent observation was possible. The care plan also revealed the resident was at risk for falls related to cognitive deficits and poor safety awareness. The goal for the quarter ([DATE]-[DATE]) was that the resident would not have any injuries from falls. One of the interventions was the use of an alarm while in the wheelchair. On [DATE], a care plan documented the resident was assessed with [REDACTED]. Review of nursing notes dated [DATE] at 5:55 p.m. revealed Resident #10 had minimal intake appetite and was poor for meal assistance and refused food. When the spoon is taken to the resident's mouth she barely opens or cries out as if she is in pain to eat. Resident has been falling asleep in her plate at the table. Review of a physician's progress report dated [DATE] revealed that Resident #10 had complained of pain to areas of her face due to shingles. The shingles had resolved, but the resident had post neuralgia pain. Neurological exam revealed the resident was unable to follow commands, nonsensical speech and confused. Resident #10 had advanced dementia. Further review of nursing notes dated ,[DATE] at 5:36 p.m. revealed that at dinner time CNA P alerted this nurse that she was not able to find the resident. This nurse stated that the resident was usually in bed after lunch and the CNA P stated that she was not in the bed. Staff immediately began room to room checks and was in the middle of checking rooms when CNA P had gone outside and reported that the resident was on the ground outside. The resident was unresponsive, was visibly breathing, but not responding to verbal stimuli. Vital signs were: Blood Pressure ,[DATE] (low); respirations 22 (fast); pulse 125 (fast) breaths per minute (BPM) and her body temperature was 107.4 degrees Fahrenheit. The resident was transported by wheelchair to the shower to wash the dirt off the face, to remove her clothing and to lower the body temperature with a cold shower. The nurse practitioner was notified, and the facility received an order to transport the resident to the ER. The nurse's note also documented on [DATE] that Resident is able to ambulate but has been encouraged to use the wheelchair by staff due to chronic pain in knees which causes her gait to be unsteady at times. Resident has been using the wheelchair today for mode of transportation up until this incident. (The outside temperature at 3:30 p.m. on [DATE] according to the local weather report was 98 to 100 degrees Fahrenheit.) Review of a hospital record dated [DATE] revealed that Resident #10 had been outside on the ground in 100 degree temperature for under 2.5 hours and a laboratory workup revealed rhabdomyolysis (condition in which damaged skeletal muscle tissue breaks down rapidly and damaged muscle cells are released into the bloodstream), urinary tract infection, and severe dehydration. The resident was administered 4 liters of IV fluids and was admitted to ICU for [REDACTED]. The ER report also included a description of the resident having multiple large blisters of both lower extremities and a wound care consult was ordered. The consult documented: Second [MEDICAL CONDITION] large blister involving the dorsum (on top of foot) of both feet and right inner thigh. A CT scan dated [DATE] also assessed the resident with exposure to excessive natural heat, urinary infection. (A consult dated [DATE] also described the wounds as consistent with 2nd [MEDICAL CONDITION] ordered xeroform to cover all wounds and lightly wrap with kerlix.) The resident was ordered [MEDICATION NAME] 2 mg Q2H per IV for pain on [DATE] as well as an antibiotic [MEDICATION NAME] ([MEDICATION NAME]) 1 gm daily. Upon being transferred to Intermediate Care, the family met with the physician to decide to transfer the resident to another nursing facility under hospice care. On [DATE], the resident was transferred to another nursing facility under hospice care with a [DIAGNOSES REDACTED]. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 10:10 a.m., LVN N stated that Resident #10 was using a wheelchair on [DATE] due to her knees not being stable and from having recently recovered from the flu and shingles. She stated that the resident usually took a nap after lunch, but instead was seen folding towels with other residents in the main dining room. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 11:20 a.m., AD F reported that the resident usually slept through activities but was alert on [DATE]. (AD F assigned the resident to fold hand towels.) Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 11:20 a.m., CNA O stated that she had assumed her duties on [DATE] at 7:00 a.m. to 3 :30 p.m. and that Resident #10 was assigned to her. She stated that due to her low cognitive function, the resident wouldn't walk and was slow getting going. She stated that she had taken her to the rest room and changed her and then brought her back to the dining room at 2:30 p.m. She stated that she gave report of the resident's activities to CNA P. She stated that Resident #10 was not strong enough to push open the door to the courtyard and theorized that another resident who usually sat next to the door may have opened it. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 3:35 p. m., CNA P stated that Resident #10 was more active on her shift, because she usually napped in the afternoon. She stated that the resident had not been active before due to the flu and shingles ([DATE]). Review of the facility's completed investigation report dated [DATE] revealed the resident was found outside of the building on the ground in the enclosed courtyard on [DATE] at approximately 17:15 (5:30 p.m.) in an area that could not be seen by a camera. CNA P's written statement reported that she had found the resident lying in the dirt, incoherent, twitching, shaking and very warm. The investigation report also revealed that Resident #10 had [MEDICAL CONDITION] her feet and legs from the heat. The resident was last seen between 3:,[DATE]:30 p.m. in the dining room. She got out into the courtyard. She was found at 5:15 p.m. when the staff couldn't find her for dinner. She does have injuries. The report also stated that a wheel chair alarm was not in place on the wheelchair that day. Further review of the facility's report revealed a written statement by CNA M that she also had worked on [DATE] and upon assuming her shift at 3:30 p.m. had gone around and checked where the residents assigned to her were located on the unit. Resident #10 was not assigned to her on that day. CNA P was assigned to the resident. During a second interview on [DATE] at 5:05 p.m., CNA P stated and described in a written statement that she had signed in on [DATE] at 2:50 p.m. and received report from CNA O. She stated that she was surprised to see Resident #10 sitting up in a wheelchair. It was not the usual wheelchair that the resident sat in. She spoke to the resident and then proceeded to take care of the other residents assigned to her. CNA P did not see the resident get up and at approximately 5:00 p.m., LVN CC asked CNA P where Resident #10 was. A search of the rooms was initiated, and CNA P found the resident outside of the building. The resident was wearing pants and a shirt. During an observation on [DATE] at 11:15 a.m., and standing in the dining room, the courtyard could be observed through 3 large panes of glass. Two of them were windows and the third was a metal door. The right side of the courtyard where the fence and building joined created a blind spot that could not be observed by looking out of the windows. There was no exit sign above the door and when pushed opened, a bell rang at the nurses' station. A fire alarm pull system was located next to the door. Stepping into the courtyard, the blind spot could be observed on the right side of the building. A camera was posted in the corner of the overhead and was pointing away from the blind spot. Stepping back into the building, the bell sounded again. Standing at the nurses' station, 5 monitors were noted located on the wall in front of the nurses' station. The monitor corresponding to the camera on the porch was pointed directly ahead and did not pick up the blind spot. Each time the door opened, the bell sounded. During an interview on [DATE] at approximately 1:55 p.m., the Director of Nurse stated that on [DATE], the day of Resident #10's incident, there was a lot of activity on the memory unit including physician visits and that it was difficult for the staff to keep track of all the residents on the unit. When the door to the backyard was opened, a bell rung at the nurses' station. The Director of Nurses was asked if anyone on the unit had heard the bell sound when Resident #10 exited. The Director of Nurses stated that she didn't not know. When asked if she felt the unit was safe, she stated that she thought so. The Director of Nurses reported that she started 15-minute staff sweeps of both courtyards on [DATE] at 6:30 p.m., in addition to monitoring the camera feeds, and directed the staff to document the observations on a log maintained at the nurses' station. During the same interview on [DATE] at approximately 1:55 p.m., the Director of Physical Environment was asked why the camera outside the door to the courtyard was not turned towards the blind spot in the courtyard after Resident #10 had fallen. He stated that doing so would prevent the nurses at the nurse's station from monitoring the rest of the courtyard. He stated that a second camera had been ordered and received but the facility had not installed the camera yet. During an interview on [DATE] at 11:20 a.m., AD F stated that she had placed Resident #10 at a table to fold towels along with other residents and at 3:30 p.m. she had clocked out of the facility. When asked who was assigned to continue monitoring the activity, she stated that there was another AD (I) on the unit until 5:30 p.m. During an interview on [DATE] at 11:30 a.m., AD I stated that she had worked on the memory unit on [DATE] and was involved with other residents in the independent dining room and could not see Resident #10 from her location. She stated that she was not able to see the residents folding towels, that she was busy with other residents and that there were few residents up at that time; and that there were other staff on the unit during the time Resident #10 exited the building. During an interview on [DATE] at approximately 4:11 p.m., Resident #10's daughter reported that the resident had been in the facility for 3 years and had passed away on [DATE]. She stated that during multiple visits during the week by family members, the resident could not recognize who they were. She stated that she did not believe that the resident had opened the door to the courtyard because she was so tiny. She believed someone else had opened it for her. She stated that she had seen [MEDICAL CONDITION] that they were awful sight to see. She stated that the resident [MEDICAL CONDITION] her elbow as well. The daughter stated that the family had ordered an autopsy because she didn't feel the death was natural. She also stated that the facility needed to lock that door and not let anyone out unsupervised. During interviews on [DATE] at approximately 6:00 p.m., Residents 15 and 16 stated that they generally sit next to the door in the main dining room and had both been counseled not to open the door to let residents outside to the courtyard. Both residents recalled the incident with Resident #10 but denied opening the door for her. During an interview on [DATE] at 2:50 p.m., LVN U, Unit Manager, was asked how long had the facility planned to have the staff continue 15 minutes checks (staff sweeps of both courtyards in addition to monitoring the camera feeds) of the outsides of the east and west porch and backyard. LVN U stated that it would continue until we come up with a better idea. During an interview on [DATE] at approximately 10:30 a.m., the pathologist conducting the autopsy stated that there was no question that heat stroke contributed to Resident #10's death due to the fall and lying outside. During the exit conference on [DATE] at approximately 5:00 p.m., the DON was asked the question how long had the facility planned to have the staff continue 15-minute checks of the outsides courtyards, and responded: until we came up with a better idea. Review of a publication dated 2009 and entitled Keeping the Elderly Safe during Summer Heat Waves, recommended that nursing homes go on alert when temperatures rise, and seniors are particularly susceptible to serious health complications from hot weather, including heat exhaustion, heatstroke, sunburns and dehydration. Many seniors are on medications such as diuretics that make them more prone to the burning rays of the sun. Just a short period of time in the sun can cause some major health complications. Heatstroke commonly affects individuals who are debilitated or fatigued. Symptoms include dizziness, weakness, nausea, rapid pulse and a body temperature of more than 102 degrees. Review of a publication dated 2012 entitled Dangers that heat waves pose to seniors, revealed that temperature control centers in the brain become less sensitive with age and may therefore not initiate the correct cooling mechanisms when the body becomes overheated. 4. Review of Resident 13's admission face sheet dated [DATE] revealed the [AGE] year old resident had been admitted on [DATE] and [DATE] with a medical history of [REDACTED]. Review of a telephone physician's orders [REDACTED]. Review of a quarterly MDS dated [DATE] revealed the resident score a 3 on the BIMS review, indicating severe cognitive deficit and was assessed with [REDACTED]. The MDS also assessed the resident's needs with extensive assistance for bed mobility, transfers and dressing, supervised walking, incontinent of urine and weighing 124 pounds at 62 inches high. Review of a care plan dated [DATE] and updated on [DATE] indicated the resident had the potential to fall related to [MEDICAL CONDITION] medication administration and the potential to wander outdoors. The interventions included observed for fall related to side effects of (dizziness, orthostatic [MEDICAL CONDITION]) usage; and identify times when resident may want to go outdoors and identify staff who can assist the resident outdoors (avoid hot, cold or times weather is not safe or suitable). Review of 2 incident reports dated [DATE] revealed the resident had fallen within the facility while ambulating down the hallway at 9:30 a.m. and was viewed on the monitor from the nurses' station going out into the courtyard at 10:35 a.m. The resident walked down the sidewalk and then turned around to come back under the porch's cover. Instead of entering the door, the resident sat down on the ground and removed her socks and shoes. The staff responded by bringing the resident back into the building. During interview on [DATE] at approximately 3:50 p.m., LVN U, Unit Manager, reported that it was Resident #12's practice to walk outside unsupervised, except by camera. The resident usually walked to the end of the sidewalk, turned left at the corner of the building and reentered from the door at the end of the 600 hall. Staff would release the magnetized door and she would re-enter the building. LVN U stated that on [DATE], she had watched the resident walk down the sidewalk and turned around. At that time, the staff ran to the door to bring her back in. The Unit Manager stated that a resident must be accompanied by a staff member when going out. (The outside temperature at that time according to the local weather was approximately 98 to 100 degrees Fahrenheit.) 5. Review of Resident # 14's admission face sheet dated [DATE] revealed the [AGE] year old resident was admitted on [DATE] and re-admitted on [DATE] with a medical history of [REDACTED]. Review of a care plan dated [DATE] and renewed on [DATE] revealed the resident had an indwelling cardiac pacemaker which was inserted [DATE]. A care plan dated [DATE] and renewed [DATE] revealed the resident had the potential to fall related to unsteady gait, wandering and poor safety awareness related to dementia. An intervention listed was if resident is wandering away from unit, stay with resident, converse and gently persuade resident to walk back to designated area with him Review of a quarterly MDS date [DATE] assessed the resident's BIMS score at 9, indicating moderate cognitive deficit in memory, limited assistance in transfers and ambulation, incontinent of bowel and bladder and requiring limited assistance with hygiene and bathing. The resident used a walker and/or wheelchair for ambulation. His weight was 160 pounds. Review of a facility history and physical dated [DATE] revealed the resident had a history of [REDACTED]. The resident at this time had an indwelling catheter. During an observation on [DATE] at approximately 4:30 p.m. (outside temperature was 100 degrees Fahrenheit according to the local weather report), Resident #14 was attempting to re-enter the main dining room from the back patio and could not keep the metal door open far enough to pull his walker into the room. The resident was struggling and was bleeding from his left elbow. The surveyor intervened and called for help. Staff responded and brought the resident into the room. A few minutes later, it was noted that the metal door frame had a small jagged edge which the staff suspected from how the resident sustained [REDACTED]. On [DATE] at 3:50 p.m., the Administrator and DON were notified of the Immediate Jeopardy (IJ) situation for the above failures and a plan of Removal was requested. The facility began corrective actions on [DATE] at 6:40 p.m. with workmen arranging for the unlocked doors to be magnetically locked, posting staff to sit and monitor the doors while the work was being performed and by in-servicing staff to continue monitoring residents to ensure safety and prevention of leaving the building and falls. The facility's Plan of Removal was provided by the Administrator and DON and was accepted on [DATE] at 3:45 p.m. It included the following steps to be taken by the facility: Action Plan - Global Approach 1. Install Exit sign by door way leading to west courtyard on [DATE] at 12:00 noon. tested at 12:05 and worked. 2. Installed 2nd camera in west courtyard on [DATE] at 7:00 p.m. This additional camera gives full view of the entire courtyard. The feed to the screen (located in front of the nurses' station) flips back and forth every 5 seconds. tested at 7:05 p.m. on [DATE] and it worked. Staff in-serviced on [DATE] about how the new camera system and monitor operated. 3. Started 15-minute staff sweeps of both courtyards on 6:30 p.m. on [DATE] and continued until the camera was installed and the doors were locked. Residents' locations are now checked every 2 hours and as needed per residents' needs. 4. Posted door monitors at both courtyard exits on [DATE] at 6:30 p.m. until maglocks were installed to ensure that no residents got out unattended. Once he maglocks were in place, the door monitors were removed. 5. Audited all care plans (43) of residents located on the secure unit (The Willow) on [DATE] to ensure they were up to date and reflected each residents' care plan was individualized. For example, at risk for falling, wandering outside, special needs and specific needs. 6. In-serviced 100 % staff on following each resident's plan of care on [DATE]. Back-up documentation was incorporated on the CNA assignment sheets so that the CNA can refer to the sheets at all times. Newly assigned and temporary staff (agency) are to be in-serviced during orientation and initial shift. 7. Installed maglock and alarm system on west courtyard on [DATE] at 8:30 p.m. tested at 8:35 p.m. and it worked. All staff (100 %) in-serviced to understand that the new maglocks unlock when the fire system goes off. Currently the facility had 2 doors that can be opened by a switch at the nursing station to exit. In-services were documented, and the system will be put in the QAPI for monitoring and follow-up. 8. Installed maglock and alarm system on the east courtyard door on [DATE] at 10:20 p.m. tested at 10:25 p.m. and it worked. Staff trained on the new system and documented in-service. 9. For both new maglock doors, the facility is discussing putting them on a release switch that would be at the nursing station to allow family members or staff to take residents out on the patio during nice weather time. Currently, the facility has one such door to each courtyard that is tied into this type of switch at the nursing station to allow for exit. 10. In-serviced 100 % staff on responding to doorbell on [DATE]. Back up documentation (assignment sheets) included. Verification of the Plan of Removal: 1. On [DATE] at 2:25 p.m., the Administrator and Director of Physical Environment demonstrated the Exit sign over the west door and demonstrated that the door was locked. All 4 exit doors were demonstrated to be locked. 2. The visibility of the 5 camera monitors located on the wall across from the nurses' station were clear and the first monitor flipped every 5 seconds to reveal the entire back porch and yard on the west side. 3. Eighteen staff members from the day and evening shifts were interviewed to determine was the were in-serviced. Two staff members provided their back-up assignment sheets. The in-service text was reviewed and reflected the updates in staff assignments and actions. The sign-in sheets were reviewed to confirm signatures. 4. Observations were made on [DATE], [DATE] and [DATE] of interactions between staff and residents. Two residents were interviewed and confirmed that they had been told not to open the doors for residents. 5. An extended survey was conducted to determine compliance in other areas of care and services.

Based on observations, interviews and record review, the facility failed to ensure that residents were free from neglect and received adequate supervision and assistance to prevent accidents for 1 of 1 residents (#10) reviewed for neglect and accidents in that: 1. Resident #10 was not provided supervision while on the memory unit and exited the unit to the fenced backyard unattended. The resident fell and sustained second [MEDICAL CONDITION] her legs and thighs from lying on hot rocks for approximately 1.5 hours. When found, Resident #10 had a body temperature of 107.5, was unresponsive and required immediate hospitalization . The resident died because of heat stroke. These failures resulted in an Immediate Jeopardy (IJ) situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at s severity level of actual harm with a scope identified as isolated until the secure unit was made safe and the entire staff was in-serviced. These deficient practices could affect 33 residents who were ambulatory and able to wander through the exit doors of the memory unit into the outside gardens and who were at risk for falls, wandering and elopement due to cognitive deficits, lack of coordination, and unsteady gait and could result in deterioration in health, heat stroke and death. The findings were: 1. Review of Resident #10's admission face sheet dated [DATE] revealed the [AGE] year old resident was admitted on [DATE] and readmitted on [DATE] with a medical history of [REDACTED]. The resident resided in the Memory/Secure Unit and was discharged on [DATE] to a hospital after an incident. Review of a quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3, indicating severe cognitive deficit, which included inattention and disorganized thinking. Resident #10 was also assessed requiring extensive assistance with transfers, ambulation, dressing, bathing and hygiene and was incontinent of bowel and bladder. The resident weighed 114 pounds and was 59 inches tall. Review of a care plan dated [DATE] revealed the resident tended to get out of her wheelchair and walk away unattended. One of the interventions was to place her in an area where frequent observation was possible. The care plan also revealed the resident was at risk for falls related to cognitive deficits and poor safety awareness. The goal for the quarter ([DATE]-[DATE]) was that the resident would not have any injuries from falls. One of the interventions was the use of an alarm while in the wheelchair. On [DATE], a care plan documented the resident was assessed with [REDACTED]. Review of nursing notes dated [DATE] at 5:55 p.m. revealed Resident #10 had minimal intake appetite and was poor for meal assistance and refused food. When the spoon is taken to the resident's mouth she barely opens or cries out as if she is in pain to eat. Resident has been falling asleep in her plate at the table. Review of a physician's progress report dated [DATE] revealed that Resident #10 had complained of pain to areas of her face due to shingles. The shingles had resolved, but the resident had post neuralgia pain. Neurological exam revealed the resident was unable to follow commands, nonsensical speech and confused. Resident #10 had advanced dementia. Further review of nursing notes dated ,[DATE] at 5:36 p.m. revealed that at dinner time CNA P alerted this nurse that she was not able to find the resident. This nurse stated that the resident was usually in bed after lunch and the CNA P stated that she was not in the bed. Staff immediately began room to room checks and was in the middle of checking rooms when CNA P had gone outside and reported that the resident was on the ground outside. The resident was unresponsive, was visibly breathing, but not responding to verbal stimuli. Vital signs were: Blood Pressure ,[DATE] (low); respirations 22 (fast); pulse 125 (fast) breaths per minute (BPM) and her body temperature was 107.4 degrees Fahrenheit. The resident was transported by wheelchair to the shower to wash the dirt off the face, to remove her clothing and to lower the body temperature with a cold shower. The nurse practitioner was notified, and the facility received an order to transport the resident to the ER. The nurse's note also documented on [DATE] that Resident is able to ambulate but has been encouraged to use the wheelchair by staff due to chronic pain in knees which causes her gait to be unsteady at times. Resident has been using the wheelchair today for mode of transportation up until this incident. (The outside temperature at 3:30 p.m. on [DATE] according to the local weather report was 98 to 100 degrees Fahrenheit.) Review of a hospital record dated [DATE] revealed that Resident #10 had been outside on the ground in 100 degree temperature for under 2.5 hours and a laboratory workup revealed rhabdomyolysis (condition in which damaged skeletal muscle tissue breaks down rapidly and damaged muscle cells are released into the bloodstream), urinary tract infection, and severe dehydration. The resident was administered 4 liters of IV fluids and was admitted to ICU for [REDACTED]. The ER report also included a description of the resident having multiple large blisters of both lower extremities and a wound care consult was ordered. The consult documented: Second [MEDICAL CONDITION] large blister involving the dorsum (on top of foot) of both feet and right inner thigh. A CT scan dated [DATE] also assessed the resident with exposure to excessive natural heat, urinary infection. (A consult dated [DATE] also described the wounds as consistent with 2nd [MEDICAL CONDITION] ordered xeroform to cover all wounds and lightly wrap with kerlix.) The resident was ordered [MEDICATION NAME] 2 mg Q2H per IV for pain on [DATE] as well as an antibiotic [MEDICATION NAME] ([MEDICATION NAME]) 1 gm daily. Upon being transferred to Intermediate Care, the family met with the physician to decide to transfer the resident to another nursing facility under hospice care. On [DATE], the resident was transferred to another nursing facility under hospice care with a [DIAGNOSES REDACTED]. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 10:10 a.m., LVN N stated that Resident #10 was using a wheelchair on [DATE] due to her knees not being stable and from having recently recovered from the flu and shingles. She stated that the resident usually took a nap after lunch, but instead was seen folding towels with other residents in the main dining room. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 11:20 a.m., AD F reported that the resident usually slept through activities but was alert on [DATE]. (AD F assigned the resident to fold hand towels.) Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 11:20 a.m., CNA O stated that she had assumed her duties on [DATE] at 7:00 a.m. to 3 :30 p.m. and that Resident #10 was assigned to her. She stated that due to her low cognitive function, the resident wouldn't walk and was slow getting going. She stated that she had taken her to the rest room and changed her and then brought her back to the dining room at 2:30 p.m. She stated that she gave report of the resident's activities to CNA P. She stated that Resident #10 was not strong enough to push open the door to the courtyard and theorized that another resident who usually sat next to the door may have opened it. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 3:35 p. m., CNA P stated that Resident #10 was more active on her shift, because she usually napped in the afternoon. She stated that the resident had not been active before due to the flu and shingles ([DATE]). Review of the facility's completed investigation report dated [DATE] revealed the resident was found outside of the building on the ground in the enclosed courtyard on [DATE] at approximately 17:15 (5:30 p.m.) in an area that could not be seen by a camera. CNA P's written statement reported that she had found the resident lying in the dirt, incoherent, twitching, shaking and very warm. The investigation report also revealed that Resident #10 had [MEDICAL CONDITION] her feet and legs from the heat. The resident was last seen between 3:,[DATE]:30 p.m. in the dining room. She got out into the courtyard. She was found at 5:15 p.m. when the staff couldn't find her for dinner. She does have injuries. The report also stated that a wheel chair alarm was not in place on the wheelchair that day. Further review of the facility's report revealed a written statement by CNA M that she also had worked on [DATE] and upon assuming her shift at 3:30 p.m. had gone around and checked where the residents assigned to her were located on the unit. Resident #10 was not assigned to her on that day. CNA P was assigned to the resident. During a second interview on [DATE] at 5:05 p.m., CNA P stated and described in a written statement that she had signed in on [DATE] at 2:50 p.m. and received report from CNA O. She stated that she was surprised to see Resident #10 sitting up in a wheelchair. It was not the usual wheelchair that the resident sat in. She spoke to the resident and then proceeded to take care of the other residents assigned to her. CNA P did not see the resident get up and at approximately 5:00 p.m., LVN CC asked CNA P where Resident #10 was. A search of the rooms was initiated, and CNA P found the resident outside of the building. The resident was wearing pants and a shirt. During an observation on [DATE] at 11:15 a.m., and standing in the dining room, the courtyard could be observed through 3 large panes of glass. Two of them were windows and the third was a metal door. The right side of the courtyard where the fence and building joined created a blind spot that could not be observed by looking out of the windows. There was no exit sign above the door and when pushed opened, a bell rang at the nurses' station. A fire alarm pull system was located next to the door. Stepping into the courtyard, the blind spot could be observed on the right side of the building. A camera was posted in the corner of the overhead and was pointing away from the blind spot. Stepping back into the building, the bell sounded again. Standing at the nurses' station, 5 monitors were noted located on the wall in front of the nurses' station. The monitor corresponding to the camera on the porch was pointed directly ahead and did not pick up the blind spot. Each time the door opened, the bell sounded. During an interview on [DATE] at approximately 1:55 p.m., the Director of Nurse stated that on [DATE], the day of Resident #10's incident, there was a lot of activity on the memory unit including physician visits and that it was difficult for the staff to keep track of all the residents on the unit. When the door to the backyard was opened, a bell rung at the nurses' station. The Director of Nurses was asked if anyone on the unit had heard the bell sound when Resident #10 exited. The Director of Nurses stated that she didn't not know. When asked if she felt the unit was safe, she stated that she thought so. The Director of Nurses reported that she started 15-minute staff sweeps of both courtyards on [DATE] at 6:30 p.m., in addition to monitoring the camera feeds, and directed the staff to document the observations on a log maintained at the nurses' station. During the same interview on [DATE] at approximately 1:55 p.m., the Director of Physical Environment was asked why the camera outside the door to the courtyard was not turned towards the blind spot in the courtyard after Resident #10 had fallen. He stated that doing so would prevent the nurses at the nurse's station from monitoring the rest of the courtyard. He stated that a second camera had been ordered and received but the facility had not installed the camera yet. During an interview on [DATE] at 11:20 a.m., AD F stated that she had placed Resident #10 at a table to fold towels along with other residents and at 3:30 p.m. she had clocked out of the facility. When asked who was assigned to continue monitoring the activity, she stated that there was another AD (I) on the unit until 5:30 p.m. During an interview on [DATE] at 11:30 a.m., AD I stated that she had worked on the memory unit on [DATE] and was involved with other residents in the independent dining room and could not see Resident #10 from her location. She stated that she was not able to see the residents folding towels, that she was busy with other residents and that there were few residents up at that time; and that there were other staff on the unit during the time Resident #10 exited the building. During an interview on [DATE] at approximately 4:11 p.m., Resident #10's daughter reported that the resident had been in the facility for 3 years and had passed away on [DATE]. She stated that during multiple visits during the week by family members, the resident could not recognize who they were. She stated that she did not believe that the resident had opened the door to the courtyard because she was so tiny. She believed someone else had opened it for her. She stated that she had seen [MEDICAL CONDITION] that they were awful sight to see. She stated that the resident [MEDICAL CONDITION] her elbow as well. The daughter stated that the family had ordered an autopsy because she didn't feel the death was natural. She also stated that the facility needed to lock that door and not let anyone out unsupervised. During interviews on [DATE] at approximately 6:00 p.m., Residents 15 and 16 stated that they generally sit next to the door in the main dining room and had both been counseled not to open the door to let residents outside to the courtyard. Both residents recalled the incident with Resident #10 but denied opening the door for her. During an interview on [DATE] at 2:50 p.m., LVN U, Unit Manager, was asked how long had the facility planned to have the staff continue 15 minutes checks (staff sweeps of both courtyards in addition to monitoring the camera feeds) of the outsides of the east and west porch and backyard. LVN U stated that it would continue until we come up with a better idea. During an interview on [DATE] at approximately 10:30 a.m., the pathologist conducting the autopsy stated that there was no question that heat stroke contributed to Resident #10's death due to the fall and lying outside. During the exit conference on [DATE] at approximately 5:00 p.m., the DON was asked the question how long had the facility planned to have the staff continue 15-minute checks of the outsides courtyards, and responded: until we came up with a better idea. Review of a publication dated 2009 and entitled Keeping the Elderly Safe during Summer Heat Waves, recommended that nursing homes go on alert when temperatures rise, and seniors are particularly susceptible to serious health complications from hot weather, including heat exhaustion, heatstroke, sunburns and dehydration. Many seniors are on medications such as diuretics that make them more prone to the burning rays of the sun. Just a short period of time in the sun can cause some major health complications. Heatstroke commonly affects individuals who are debilitated or fatigued. Symptoms include dizziness, weakness, nausea, rapid pulse and a body temperature of more than 102 degrees. Review of a publication dated 2012 entitled Dangers that heat waves pose to seniors, revealed that temperature control centers in the brain become less sensitive with age and may therefore not initiate the correct cooling mechanisms when the body becomes overheated. On [DATE] at 3:50 p.m., the Administrator and DON were notified of the Immediate Jeopardy (IJ) situation for the above failures and a plan of Removal was requested. The facility began corrective actions on [DATE] at 6:40 p.m. with workmen arranging for the unlocked doors to be magnetically locked, posting staff to sit and monitor the doors while the work was being performed and by in-servicing staff to continue monitoring residents to ensure safety and prevention of leaving the building and falls. The facility's Plan of Removal was provided by the Administrator and DON and was accepted on [DATE] at 3:45 p.m. It included the following steps to be taken by the facility: Action Plan - Global Approach 1. Install Exit sign by door way leading to west courtyard on [DATE] at 12:00 noon. tested at 12:05 and worked. 2. Installed 2nd camera in west courtyard on [DATE] at 7:00 p.m. This additional camera gives full view of the entire courtyard. The feed to the screen (located in front of the nurses' station) flips back and forth every 5 seconds. tested at 7:05 p.m. on [DATE] and it worked. Staff in-serviced on [DATE] about how the new camera system and monitor operated. 3. Started 15-minute staff sweeps of both courtyards on 6:30 p.m. on [DATE] and continued until the camera was installed and the doors were locked. Residents' locations are now checked every 2 hours and as needed per residents' needs. 4. Posted door monitors at both courtyard exits on [DATE] at 6:30 p.m. until maglocks were installed to ensure that no residents got out unattended. Once he maglocks were in place, the door monitors were removed. 5. Audited all care plans (43) of residents located on the secure unit (The Willow) on [DATE] to ensure they were up to date and reflected each residents' care plan was individualized. For example, at risk for falling, wandering outside, special needs and specific needs. 6. In-serviced 100 % staff on following each resident's plan of care on [DATE]. Back-up documentation was incorporated on the CNA assignment sheets so that the CNA can refer to the sheets at all times. Newly assigned and temporary staff (agency) are to be in-serviced during orientation and initial shift. 7. Installed maglock and alarm system on west courtyard on [DATE] at 8:30 p.m. tested at 8:35 p.m. and it worked. All staff (100 %) in-serviced to understand that the new maglocks unlock when the fire system goes off. Currently the facility had 2 doors that can be opened by a switch at the nursing station to exit. In-services were documented, and the system will be put in the QAPI for monitoring and follow-up. 8. Installed maglock and alarm system on the east courtyard door on [DATE] at 10:20 p.m. tested at 10:25 p.m. and it worked. Staff trained on the new system and documented in-service. 9. For both new maglock doors, the facility is discussing putting them on a release switch that would be at the nursing station to allow family members or staff to take residents out on the patio during nice weather time. Currently, the facility has one such door to each courtyard that is tied into this type of switch at the nursing station to allow for exit. 10. In-serviced 100 % staff on responding to doorbell on [DATE]. Back up documentation (assignment sheets) included. Verification of the Plan of Removal: 1. On [DATE] at 2:25 p.m., the Administrator and Director of Physical Environment demonstrated the Exit sign over the west door and demonstrated that the door was locked. All 4 exit doors were demonstrated to be locked. 2. The visibility of the 5 camera monitors located on the wall across from the nurses' station were clear and the first monitor flipped every 5 seconds to reveal the entire back porch and yard on the west side. 3. Eighteen staff members from the day and evening shifts were interviewed to determine was the were in-serviced. Two staff members provided their back-up assignment sheets. The in-service text was reviewed and reflected the updates in staff assignments and actions. The sign-in sheets were reviewed to confirm signatures. 4. Observations were made on [DATE], [DATE] and [DATE] of interactions between staff and residents. Two residents were interviewed and confirmed that they had been told not to open the doors for residents. 5. An extended survey was conducted to determine compliance in other areas of care and services. This included review of a sample of staff personnel files, Employee Misconduct Checks and Criminal History Checks. Contracts were reviewed to determine they were in place. Licensing compliance was also checked to include CLIA waiver, Surety Bond to cover Trust Funds, Emergency Potable Water Supply, signed policies and contracts for outsource services. On [DATE] at 3:45 p.m., the Administrator and DON were informed that the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. The facility identified on [DATE] identified 33 residents on the memory unit as ambulatory and able to go out into the courtyard unsupervised.

Based on observations, interviews and record review, the facility failed to develop and implement written policies and procedures to prevent neglect for 1 of 1 residents (#10) reviewed for neglect in that: 1. Resident #10 was not provided supervision while on the memory unit and exited the unit to the fenced backyard unattended. The resident fell and sustained second [MEDICAL CONDITION] her legs and thighs from lying on rocks for approximately 1.5 hours. When found, Resident #10 had a body temperature of 107.5, was unresponsive and required immediate hospitalization . The resident died because of heat stroke. These failures resulted in an Immediate Jeopardy (IJ) situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at s severity level of actual harm with a scope identified as isolated until the secure unit was made safe and the entire staff was in-serviced. These deficient practices could affect 33 residents who were ambulatory and able to wander through the exit doors of the memory unit into the outside gardens and who were at risk for falls, wandering and elopement due to cognitive deficits, lack of coordination, and unsteady gait and could result in deterioration in health, heat stroke and death. Review of the facility alleged abuse/neglect or exploitation policy date [DATE] revealed that neglect was the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility's policy on investigative procedures dated [DATE] revealed that a deficient practice was defined as an inadequate systemic procedure that addresses the needs of the resident. The department may identify a deficient practice when a facility fails to: report all incidents and allegations of abuse; thoroughly investigate and document all incidents and allegation of abuse; properly assess residents, upon initial and annual assessment, as well as upon significant change in condition; or implement a plan of action to prevent recurrence of incidents or abuse. The findings were: 1. Review of Resident #10's admission face sheet dated [DATE] revealed the [AGE] year old resident was admitted on [DATE] and readmitted on [DATE] with a medical history of [REDACTED]. The resident resided in the Memory/Secure Unit and was discharged on [DATE] to a hospital after an incident. Review of a quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3, indicating severe cognitive deficit, which included inattention and disorganized thinking. Resident #10 was also assessed requiring extensive assistance with transfers, ambulation, dressing, bathing and hygiene and was incontinent of bowel and bladder. The resident weighed 114 pounds and was 59 inches tall. Review of a care plan dated [DATE] revealed the resident tended to get out of her wheelchair and walk away unattended. One of the interventions was to place her in an area where frequent observation was possible. The care plan also revealed the resident was at risk for falls related to cognitive deficits and poor safety awareness. The goal for the quarter ([DATE]-[DATE]) was that the resident would not have any injuries from falls. One of the interventions was the use of an alarm while in the wheelchair. On [DATE], a care plan documented the resident was assessed with [REDACTED]. Review of nursing notes dated [DATE] at 5:55 p.m. revealed Resident #10 had minimal intake appetite and was poor for meal assistance and refused food. When the spoon is taken to the resident's mouth she barely opens or cries out as if she is in pain to eat. Resident has been falling asleep in her plate at the table. Review of a physician's progress report dated [DATE] revealed that Resident #10 had complained of pain to areas of her face due to shingles. The shingles had resolved, but the resident had post neuralgia pain. Neurological exam revealed the resident was unable to follow commands, nonsensical speech and confused. Resident #10 had advanced dementia. Further review of nursing notes dated ,[DATE] at 5:36 p.m. revealed that at dinner time CNA P alerted this nurse that she was not able to find the resident. This nurse stated that the resident was usually in bed after lunch and the CNA P stated that she was not in the bed. Staff immediately began room to room checks and was in the middle of checking rooms when CNA P had gone outside and reported that the resident was on the ground outside. The resident was unresponsive, was visibly breathing, but not responding to verbal stimuli. Vital signs were: Blood Pressure ,[DATE] (low); respirations 22 (fast); pulse 125 (fast) breaths per minute (BPM) and her body temperature was 107.4 degrees Fahrenheit. The resident was transported by wheelchair to the shower to wash the dirt off the face, to remove her clothing and to lower the body temperature with a cold shower. The nurse practitioner was notified, and the facility received an order to transport the resident to the ER. The nurse's note also documented on [DATE] that Resident is able to ambulate but has been encouraged to use the wheelchair by staff due to chronic pain in knees which causes her gait to be unsteady at times. Resident has been using the wheelchair today for mode of transportation up until this incident. (The outside temperature at 3:30 p.m. on [DATE] according to the local weather report was 98 to 100 degrees Fahrenheit.) Review of a hospital record dated [DATE] revealed that Resident #10 had been outside on the ground in 100 degree temperature for under 2.5 hours and a laboratory workup revealed rhabdomyolysis (condition in which damaged skeletal muscle tissue breaks down rapidly and damaged muscle cells are released into the bloodstream), urinary tract infection, and severe dehydration. The resident was administered 4 liters of IV fluids and was admitted to ICU for [REDACTED]. The ER report also included a description of the resident having multiple large blisters of both lower extremities and a wound care consult was ordered. The consult documented: Second [MEDICAL CONDITION] large blister involving the dorsum (on top of foot) of both feet and right inner thigh. A CT scan dated [DATE] also assessed the resident with exposure to excessive natural heat, urinary infection. (A consult dated [DATE] also described the wounds as consistent with 2nd [MEDICAL CONDITION] ordered xeroform to cover all wounds and lightly wrap with kerlix.) The resident was ordered [MEDICATION NAME] 2 mg Q2H per IV for pain on [DATE] as well as an antibiotic [MEDICATION NAME] ([MEDICATION NAME]) 1 gm daily. Upon being transferred to Intermediate Care, the family met with the physician to decide to transfer the resident to another nursing facility under hospice care. On [DATE], the resident was transferred to another nursing facility under hospice care with a [DIAGNOSES REDACTED]. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 10:10 a.m., LVN N stated that Resident #10 was using a wheelchair on [DATE] due to her knees not being stable and from having recently recovered from the flu and shingles. She stated that the resident usually took a nap after lunch, but instead was seen folding towels with other residents in the main dining room. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 11:20 a.m., AD F reported that the resident usually slept through activities but was alert on [DATE]. (AD F assigned the resident to fold hand towels.) Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 11:20 a.m., CNA O stated that she had assumed her duties on [DATE] at 7:00 a.m. to 3 :30 p.m. and that Resident #10 was assigned to her. She stated that due to her low cognitive function, the resident wouldn't walk and was slow getting going. She stated that she had taken her to the rest room and changed her and then brought her back to the dining room at 2:30 p.m. She stated that she gave report of the resident's activities to CNA P. She stated that Resident #10 was not strong enough to push open the door to the courtyard and theorized that another resident who usually sat next to the door may have opened it. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 3:35 p. m., CNA P stated that Resident #10 was more active on her shift, because she usually napped in the afternoon. She stated that the resident had not been active before due to the flu and shingles ([DATE]). Review of the facility's completed investigation report dated [DATE] revealed the resident was found outside of the building on the ground in the enclosed courtyard on [DATE] at approximately 17:15 (5:30 p.m.) in an area that could not be seen by a camera. CNA P's written statement reported that she had found the resident lying in the dirt, incoherent, twitching, shaking and very warm. The investigation report also revealed that Resident #10 had [MEDICAL CONDITION] her feet and legs from the heat. The resident was last seen between 3:,[DATE]:30 p.m. in the dining room. She got out into the courtyard. She was found at 5:15 p.m. when the staff couldn't find her for dinner. She does have injuries. The report also stated that a wheel chair alarm was not in place on the wheelchair that day. Further review of the facility's report revealed a written statement by CNA M that she also had worked on [DATE] and upon assuming her shift at 3:30 p.m. had gone around and checked where the residents assigned to her were located on the unit. Resident #10 was not assigned to her on that day. CNA P was assigned to the resident. During a second interview on [DATE] at 5:05 p.m., CNA P stated and described in a written statement that she had signed in on [DATE] at 2:50 p.m. and received report from CNA O. She stated that she was surprised to see Resident #10 sitting up in a wheelchair. It was not the usual wheelchair that the resident sat in. She spoke to the resident and then proceeded to take care of the other residents assigned to her. CNA P did not see the resident get up and at approximately 5:00 p.m., LVN CC asked CNA P where Resident #10 was. A search of the rooms was initiated, and CNA P found the resident outside of the building. The resident was wearing pants and a shirt. During an observation on [DATE] at 11:15 a.m., and standing in the dining room, the courtyard could be observed through 3 large panes of glass. Two of them were windows and the third was a metal door. The right side of the courtyard where the fence and building joined created a blind spot that could not be observed by looking out of the windows. There was no exit sign above the door and when pushed opened, a bell rang at the nurses' station. A fire alarm pull system was located next to the door. Stepping into the courtyard, the blind spot could be observed on the right side of the building. A camera was posted in the corner of the overhead and was pointing away from the blind spot. Stepping back into the building, the bell sounded again. Standing at the nurses' station, 5 monitors were noted located on the wall in front of the nurses' station. The monitor corresponding to the camera on the porch was pointed directly ahead and did not pick up the blind spot. Each time the door opened, the bell sounded. During an interview on [DATE] at approximately 1:55 p.m., the Director of Nurse stated that on [DATE], the day of Resident #10's incident, there was a lot of activity on the memory unit including physician visits and that it was difficult for the staff to keep track of all the residents on the unit. When the door to the backyard was opened, a bell rung at the nurses' station. The Director of Nurses was asked if anyone on the unit had heard the bell sound when Resident #10 exited. The Director of Nurses stated that she didn't not know. When asked if she felt the unit was safe, she stated that she thought so. The Director of Nurses reported that she started 15-minute staff sweeps of both courtyards on [DATE] at 6:30 p.m., in addition to monitoring the camera feeds, and directed the staff to document the observations on a log maintained at the nurses' station. During the same interview on [DATE] at approximately 1:55 p.m., the Director of Physical Environment was asked why the camera outside the door to the courtyard was not turned towards the blind spot in the courtyard after Resident #10 had fallen. He stated that doing so would prevent the nurses at the nurse's station from monitoring the rest of the courtyard. He stated that a second camera had been ordered and received but the facility had not installed the camera yet. During an interview on [DATE] at 11:20 a.m., AD F stated that she had placed Resident #10 at a table to fold towels along with other residents and at 3:30 p.m. she had clocked out of the facility. When asked who was assigned to continue monitoring the activity, she stated that there was another AD (I) on the unit until 5:30 p.m. During an interview on [DATE] at 11:30 a.m., AD I stated that she had worked on the memory unit on [DATE] and was involved with other residents in the independent dining room and could not see Resident #10 from her location. She stated that she was not able to see the residents folding towels, that she was busy with other residents and that there were few residents up at that time; and that there were other staff on the unit during the time Resident #10 exited the building. During an interview on [DATE] at approximately 4:11 p.m., Resident #10's daughter reported that the resident had been in the facility for 3 years and had passed away on [DATE]. She stated that during multiple visits during the week by family members, the resident could not recognize who they were. She stated that she did not believe that the resident had opened the door to the courtyard because she was so tiny. She believed someone else had opened it for her. She stated that she had seen [MEDICAL CONDITION] that they were awful sight to see. She stated that the resident [MEDICAL CONDITION] her elbow as well. The daughter stated that the family had ordered an autopsy because she didn't feel the death was natural. She also stated that the facility needed to lock that door and not let anyone out unsupervised. During interviews on [DATE] at approximately 6:00 p.m., Residents 15 and 16 stated that they generally sit next to the door in the main dining room and had both been counseled not to open the door to let residents outside to the courtyard. Both residents recalled the incident with Resident #10 but denied opening the door for her. During an interview on [DATE] at 2:50 p.m., LVN U, Unit Manager, was asked how long had the facility planned to have the staff continue 15 minutes checks (staff sweeps of both courtyards in addition to monitoring the camera feeds) of the outsides of the east and west porch and backyard. LVN U stated that it would continue until we come up with a better idea. During an interview on [DATE] at approximately 10:30 a.m., the pathologist conducting the autopsy stated that there was no question that heat stroke contributed to Resident #10's death due to the fall and lying outside. During the exit conference on [DATE] at approximately 5:00 p.m., the DON was asked the question how long had the facility planned to have the staff continue 15-minute checks of the outsides courtyards, and responded: until we came up with a better idea. Review of a publication dated 2009 and entitled Keeping the Elderly Safe during Summer Heat Waves, recommended that nursing homes go on alert when temperatures rise, and seniors are particularly susceptible to serious health complications from hot weather, including heat exhaustion, heatstroke, sunburns and dehydration. Many seniors are on medications such as diuretics that make them more prone to the burning rays of the sun. Just a short period of time in the sun can cause some major health complications. Heatstroke commonly affects individuals who are debilitated or fatigued. Symptoms include dizziness, weakness, nausea, rapid pulse and a body temperature of more than 102 degrees. Review of a publication dated 2012 entitled Dangers that heat waves pose to seniors, revealed that temperature control centers in the brain become less sensitive with age and may therefore not initiate the correct cooling mechanisms when the body becomes overheated. On [DATE] at 3:50 p.m., the Administrator and DON were notified of the Immediate Jeopardy (IJ) situation for the above failures and a plan of Removal was requested. The facility began corrective actions on [DATE] at 6:40 p.m. with workmen arranging for the unlocked doors to be magnetically locked, posting staff to sit and monitor the doors while the work was being performed and by in-servicing staff to continue monitoring residents to ensure safety and prevention of leaving the building and falls. The facility's Plan of Removal was provided by the Administrator and DON and was accepted on [DATE] at 3:45 p.m. It included the following steps to be taken by the facility: Action Plan - Global Approach 1. Install Exit sign by door way leading to west courtyard on [DATE] at 12:00 noon. tested at 12:05 and worked. 2. Installed 2nd camera in west courtyard on [DATE] at 7:00 p.m. This additional camera gives full view of the entire courtyard. The feed to the screen (located in front of the nurses' station) flips back and forth every 5 seconds. tested at 7:05 p.m. on [DATE] and it worked. Staff in-serviced on [DATE] about how the new camera system and monitor operated. 3. Started 15-minute staff sweeps of both courtyards on 6:30 p.m. on [DATE] and continued until the camera was installed and the doors were locked. Residents' locations are now checked every 2 hours and as needed per residents' needs. 4. Posted door monitors at both courtyard exits on [DATE] at 6:30 p.m. until maglocks were installed to ensure that no residents got out unattended. Once he maglocks were in place, the door monitors were removed. 5. Audited all care plans (43) of residents located on the secure unit (The Willow) on [DATE] to ensure they were up to date and reflected each residents' care plan was individualized. For example, at risk for falling, wandering outside, special needs and specific needs. 6. In-serviced 100 % staff on following each resident's plan of care on [DATE]. Back-up documentation was incorporated on the CNA assignment sheets so that the CNA can refer to the sheets at all times. Newly assigned and temporary staff (agency) are to be in-serviced during orientation and initial shift. 7. Installed maglock and alarm system on west courtyard on [DATE] at 8:30 p.m. tested at 8:35 p.m. and it worked. All staff (100 %) in-serviced to understand that the new maglocks unlock when the fire system goes off. Currently the facility had 2 doors that can be opened by a switch at the nursing station to exit. In-services were documented, and the system will be put in the QAPI for monitoring and follow-up. 8. Installed maglock and alarm system on the east courtyard door on [DATE] at 10:20 p.m. tested at 10:25 p.m. and it worked. Staff trained on the new system and documented in-service. 9. For both new maglock doors, the facility is discussing putting them on a release switch that would be at the nursing station to allow family members or staff to take residents out on the patio during nice weather time. Currently, the facility has one such door to each courtyard that is tied into this type of switch at the nursing station to allow for exit. 10. In-serviced 100 % staff on responding to doorbell on [DATE]. Back up documentation (assignment sheets) included. Verification of the Plan of Removal: 1. On [DATE] at 2:25 p.m., the Administrator and Director of Physical Environment demonstrated the Exit sign over the west door and demonstrated that the door was locked. All 4 exit doors were demonstrated to be locked. 2. The visibility of the 5 camera monitors located on the wall across from the nurses' station were clear and the first monitor flipped every 5 seconds to reveal the entire back porch and yard on the west side. 3. Eighteen staff members from the day and evening shifts were interviewed to determine was the were in-serviced. Two staff members provided their back-up assignment sheets. The in-service text was reviewed and reflected the updates in staff assignments and actions. The sign-in sheets were reviewed to confirm signatures. 4. Observations were made on [DATE], [DATE] and [DATE] of interactions between staff and residents. Two residents were interviewed and confirmed that they had been told not to open the doors for residents. 5. An extended survey was conducted to determine compliance in other areas of care and services. This included review of a sample of staff personnel files, Employee Misconduct Checks and Criminal History Checks. Contracts were reviewed to determine they were in place. Licensing compliance was also checked to include CLIA waiver, Surety Bond to cover Trust Funds, Emergency Potable Water Supply, signed policies and contracts for outsource services. On [DATE] at 3:45 p.m., the Administrator and DON were informed that the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. The facility identified on [DATE] identified 33 residents on the memory unit as ambulatory and able to go out into the courtyard unsupervised.

Based on observations, interviews and record review, the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents for 4 of 4 residents (#9, 10, 13 and 14) reviewed for accidents in that: 1. Resident #10 was not provided supervision while on the memory unit and exited the unit to the fenced backyard unattended. The resident fell and sustained second [MEDICAL CONDITION] her legs and thighs from lying on hot rocks for approximately 1.5 hours. When found, Resident #10 had a body temperature of 107.5, was unresponsive and required immediate hospitalization . The resident died because of heat stroke. 2. Resident #9 was not ambulated with a gait belt and was unable to maneuver himself through a doorway with an elevated surface when being provided physical therapy resulting in the resident falling forward and hitting his forehead on the floor and sustaining a large laceration to the right hand requiring 20 sutures, left toe nail removed and a small laceration to the right forehead. 3. Resident #13 had a history of [REDACTED]. 4. Resident #14 was not provided supervision when he exited the memory unit to the backyard with his walker when the outside temperature was 100 degrees. When attempting to reenter the unit, his walker became trapped by the heavy metal door and he sustained a skin tear to his right elbow on a sharp, jagged edge on the metal door frame. The resident had an implanted cardiac pacemaker and had a history of [REDACTED]. These failures resulted in an Immediate Jeopardy (IJ) situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at s severity level of actual harm with a scope identified as isolated until the secure unit was made safe and the entire staff was in-serviced. These deficient practices could affect 33 residents who were ambulatory and able to wander through the exit doors of the memory unit into the outside gardens and who were at risk for falls, wandering and elopement due to cognitive deficits, lack of coordination, and unsteady gait and could result in deterioration in health, heat stroke and death. The findings were: 1. Review of Resident #10's admission face sheet dated [DATE] revealed the [AGE] year old resident was admitted on [DATE] and readmitted on [DATE] with a medical history of [REDACTED]. The resident resided in the Memory/Secure Unit and was discharged on [DATE] to a hospital after an incident. Review of a quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3, indicating severe cognitive deficit, which included inattention and disorganized thinking. Resident #10 was also assessed requiring extensive assistance with transfers, ambulation, dressing, bathing and hygiene and was incontinent of bowel and bladder. The resident weighed 114 pounds and was 59 inches tall. Review of a care plan dated [DATE] revealed the resident tended to get out of her wheelchair and walk away unattended. One of the interventions was to place her in an area where frequent observation was possible. The care plan also revealed the resident was at risk for falls related to cognitive deficits and poor safety awareness. The goal for the quarter ([DATE]-[DATE]) was that the resident would not have any injuries from falls. One of the interventions was the use of an alarm while in the wheelchair. On [DATE], a care plan documented the resident was assessed with [REDACTED]. Review of nursing notes dated [DATE] at 5:55 p.m. revealed Resident #10 had minimal intake appetite and was poor for meal assistance and refused food. When the spoon is taken to the resident's mouth she barely opens or cries out as if she is in pain to eat. Resident has been falling asleep in her plate at the table. Review of a physician's progress report dated [DATE] revealed that Resident #10 had complained of pain to areas of her face due to shingles. The shingles had resolved, but the resident had post neuralgia pain. Neurological exam revealed the resident was unable to follow commands, nonsensical speech and confused. Resident #10 had advanced dementia. Further review of nursing notes dated ,[DATE] at 5:36 p.m. revealed that at dinner time CNA P alerted this nurse that she was not able to find the resident. This nurse stated that the resident was usually in bed after lunch and the CNA P stated that she was not in the bed. Staff immediately began room to room checks and was in the middle of checking rooms when CNA P had gone outside and reported that the resident was on the ground outside. The resident was unresponsive, was visibly breathing, but not responding to verbal stimuli. Vital signs were: Blood Pressure ,[DATE] (low); respirations 22 (fast); pulse 125 (fast) breaths per minute (BPM) and her body temperature was 107.4 degrees Fahrenheit. The resident was transported by wheelchair to the shower to wash the dirt off the face, to remove her clothing and to lower the body temperature with a cold shower. The nurse practitioner was notified, and the facility received an order to transport the resident to the ER. The nurse's note also documented on [DATE] that Resident is able to ambulate but has been encouraged to use the wheelchair by staff due to chronic pain in knees which causes her gait to be unsteady at times. Resident has been using the wheelchair today for mode of transportation up until this incident. (The outside temperature at 3:30 p.m. on [DATE] according to the local weather report was 98 to 100 degrees Fahrenheit.) Review of a hospital record dated [DATE] revealed that Resident #10 had been outside on the ground in 100 degree temperature for under 2.5 hours and a laboratory workup revealed rhabdomyolysis (condition in which damaged skeletal muscle tissue breaks down rapidly and damaged muscle cells are released into the bloodstream), urinary tract infection, and severe dehydration. The resident was administered 4 liters of IV fluids and was admitted to ICU for [REDACTED]. The ER report also included a description of the resident having multiple large blisters of both lower extremities and a wound care consult was ordered. The consult documented: Second [MEDICAL CONDITION] large blister involving the dorsum (on top of foot) of both feet and right inner thigh. A CT scan dated [DATE] also assessed the resident with exposure to excessive natural heat, urinary infection. (A consult dated [DATE] also described the wounds as consistent with 2nd [MEDICAL CONDITION] ordered xeroform to cover all wounds and lightly wrap with kerlix.) The resident was ordered [MEDICATION NAME] 2 mg Q2H per IV for pain on [DATE] as well as an antibiotic [MEDICATION NAME] ([MEDICATION NAME]) 1 gm daily. Upon being transferred to Intermediate Care, the family met with the physician to decide to transfer the resident to another nursing facility under hospice care. On [DATE], the resident was transferred to another nursing facility under hospice care with a [DIAGNOSES REDACTED]. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 10:10 a.m., LVN N stated that Resident #10 was using a wheelchair on [DATE] due to her knees not being stable and from having recently recovered from the flu and shingles. She stated that the resident usually took a nap after lunch, but instead was seen folding towels with other residents in the main dining room. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 11:20 a.m., AD F reported that the resident usually slept through activities but was alert on [DATE]. (AD F assigned the resident to fold hand towels.) Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 11:20 a.m., CNA O stated that she had assumed her duties on [DATE] at 7:00 a.m. to 3 :30 p.m. and that Resident #10 was assigned to her. She stated that due to her low cognitive function, the resident wouldn't walk and was slow getting going. She stated that she had taken her to the rest room and changed her and then brought her back to the dining room at 2:30 p.m. She stated that she gave report of the resident's activities to CNA P. She stated that Resident #10 was not strong enough to push open the door to the courtyard and theorized that another resident who usually sat next to the door may have opened it. Review of a statement given at an investigation conducted on [DATE] revealed that at approximately 3:35 p. m., CNA P stated that Resident #10 was more active on her shift, because she usually napped in the afternoon. She stated that the resident had not been active before due to the flu and shingles ([DATE]). Review of the facility's completed investigation report dated [DATE] revealed the resident was found outside of the building on the ground in the enclosed courtyard on [DATE] at approximately 17:15 (5:30 p.m.) in an area that could not be seen by a camera. CNA P's written statement reported that she had found the resident lying in the dirt, incoherent, twitching, shaking and very warm. The investigation report also revealed that Resident #10 had [MEDICAL CONDITION] her feet and legs from the heat. The resident was last seen between 3:,[DATE]:30 p.m. in the dining room. She got out into the courtyard. She was found at 5:15 p.m. when the staff couldn't find her for dinner. She does have injuries. The report also stated that a wheel chair alarm was not in place on the wheelchair that day. Further review of the facility's report revealed a written statement by CNA M that she also had worked on [DATE] and upon assuming her shift at 3:30 p.m. had gone around and checked where the residents assigned to her were located on the unit. Resident #10 was not assigned to her on that day. CNA P was assigned to the resident. During a second interview on [DATE] at 5:05 p.m., CNA P stated and described in a written statement that she had signed in on [DATE] at 2:50 p.m. and received report from CNA O. She stated that she was surprised to see Resident #10 sitting up in a wheelchair. It was not the usual wheelchair that the resident sat in. She spoke to the resident and then proceeded to take care of the other residents assigned to her. CNA P did not see the resident get up and at approximately 5:00 p.m., LVN CC asked CNA P where Resident #10 was. A search of the rooms was initiated, and CNA P found the resident outside of the building. The resident was wearing pants and a shirt. During an observation on [DATE] at 11:15 a.m., and standing in the dining room, the courtyard could be observed through 3 large panes of glass. Two of them were windows and the third was a metal door. The right side of the courtyard where the fence and building joined created a blind spot that could not be observed by looking out of the windows. There was no exit sign above the door and when pushed opened, a bell rang at the nurses' station. A fire alarm pull system was located next to the door. Stepping into the courtyard, the blind spot could be observed on the right side of the building. A camera was posted in the corner of the overhead and was pointing away from the blind spot. Stepping back into the building, the bell sounded again. Standing at the nurses' station, 5 monitors were noted located on the wall in front of the nurses' station. The monitor corresponding to the camera on the porch was pointed directly ahead and did not pick up the blind spot. Each time the door opened, the bell sounded. During an interview on [DATE] at approximately 1:55 p.m., the Director of Nurse stated that on [DATE], the day of Resident #10's incident, there was a lot of activity on the memory unit including physician visits and that it was difficult for the staff to keep track of all the residents on the unit. When the door to the backyard was opened, a bell rung at the nurses' station. The Director of Nurses was asked if anyone on the unit had heard the bell sound when Resident #10 exited. The Director of Nurses stated that she didn't not know. When asked if she felt the unit was safe, she stated that she thought so. The Director of Nurses reported that she started 15-minute staff sweeps of both courtyards on [DATE] at 6:30 p.m., in addition to monitoring the camera feeds, and directed the staff to document the observations on a log maintained at the nurses' station. During the same interview on [DATE] at approximately 1:55 p.m., the Director of Physical Environment was asked why the camera outside the door to the courtyard was not turned towards the blind spot in the courtyard after Resident #10 had fallen. He stated that doing so would prevent the nurses at the nurse's station from monitoring the rest of the courtyard. He stated that a second camera had been ordered and received but the facility had not installed the camera yet. During an interview on [DATE] at 11:20 a.m., AD F stated that she had placed Resident #10 at a table to fold towels along with other residents and at 3:30 p.m. she had clocked out of the facility. When asked who was assigned to continue monitoring the activity, she stated that there was another AD (I) on the unit until 5:30 p.m. During an interview on [DATE] at 11:30 a.m., AD I stated that she had worked on the memory unit on [DATE] and was involved with other residents in the independent dining room and could not see Resident #10 from her location. She stated that she was not able to see the residents folding towels, that she was busy with other residents and that there were few residents up at that time; and that there were other staff on the unit during the time Resident #10 exited the building. During an interview on [DATE] at approximately 4:11 p.m., Resident #10's daughter reported that the resident had been in the facility for 3 years and had passed away on [DATE]. She stated that during multiple visits during the week by family members, the resident could not recognize who they were. She stated that she did not believe that the resident had opened the door to the courtyard because she was so tiny. She believed someone else had opened it for her. She stated that she had seen [MEDICAL CONDITION] that they were awful sight to see. She stated that the resident [MEDICAL CONDITION] her elbow as well. The daughter stated that the family had ordered an autopsy because she didn't feel the death was natural. She also stated that the facility needed to lock that door and not let anyone out unsupervised. During interviews on [DATE] at approximately 6:00 p.m., Residents 15 and 16 stated that they generally sit next to the door in the main dining room and had both been counseled not to open the door to let residents outside to the courtyard. Both residents recalled the incident with Resident #10 but denied opening the door for her. During an interview on [DATE] at 2:50 p.m., LVN U, Unit Manager, was asked how long had the facility planned to have the staff continue 15 minutes checks (staff sweeps of both courtyards in addition to monitoring the camera feeds) of the outsides of the east and west porch and backyard. LVN U stated that it would continue until we come up with a better idea. During an interview on [DATE] at approximately 10:30 a.m., the pathologist conducting the autopsy stated that there was no question that heat stroke contributed to Resident #10's death due to the fall and lying outside. During the exit conference on [DATE] at approximately 5:00 p.m., the DON was asked the question how long had the facility planned to have the staff continue 15-minute checks of the outsides courtyards, and responded: until we came up with a better idea. Review of a publication dated 2009 and entitled Keeping the Elderly Safe during Summer Heat Waves, recommended that nursing homes go on alert when temperatures rise, and seniors are particularly susceptible to serious health complications from hot weather, including heat exhaustion, heatstroke, sunburns and dehydration. Many seniors are on medications such as diuretics that make them more prone to the burning rays of the sun. Just a short period of time in the sun can cause some major health complications. Heatstroke commonly affects individuals who are debilitated or fatigued. Symptoms include dizziness, weakness, nausea, rapid pulse and a body temperature of more than 102 degrees. Review of a publication dated 2012 entitled Dangers that heat waves pose to seniors, revealed that temperature control centers in the brain become less sensitive with age and may therefore not initiate the correct cooling mechanisms when the body becomes overheated. 2. Review of Resident #9's admission face sheet dated [DATE] revealed the [AGE] year old resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Additional medical conditions included dysphagia, lack of coordination and unspecified head injury, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of a physician's initial history and physical dated [DATE] revealed the resident had a history of [REDACTED]. Review of a quarterly MDS dated [DATE] assessed the resident's BIM score as 5, indicating severe cognitive deficit, requiring limited assistance in transfers, an inability to walk, total assistance with hygiene and bathing, at risk for falls and incontinent of bowel and bladder. The resident was also assessed for continuous use of oxygen therapy. Review of telephone physician orders [REDACTED]. Review of an incident report dated [DATE] revealed the resident was being ambulated at approximately 4:00 p.m. by a COTA when the resident fell and sustained a large laceration to the right hand requiring 20 sutures, the loss of a toe nail to the left foot and a small laceration to the right forehead. The resident was wearing flip flop sandals at the time and was receiving oxygen via nasal cannula from a portable oxygen tank attached to a wheelchair. Review of a care plan dated [DATE] after the day of the fall revealed the resident was to wear proper footwear when ambulating. Review of the facility's completed investigation report dated [DATE] revealed that COTA K was walking Resident #9 inside the nursing home off the nursing unit and had ambulated 125 feet and as they were going through a doorway and COTA K was behind the resident and the resident lost his balance on the threshold on the door. Review of a written statement by LVN L revealed that she had initially assessed the resident while the resident was on the floor with blood on his clothing and drops of blood on the floor. The resident was wearing slip on sandals and no socks. The COTA K stated to LVN L that she was behind the resident's wheelchair and portable oxygen when he tripped and fell . The resident was not wearing a gait belt. During an interview on [DATE] at approximately 12:00 p.m., COTA K stated that she did not use a gait belt when walking Resident # 9 and instead maintained contact guard. The resident was using a cane in his right hand. When approaching a doorway near the pharmacy with 2 swinging doors, a metal railing in the middle of the door way and an elevated rubberized surfaced, COTA K encouraged Resident #9 to cross the threshold holding onto the railing and losing the contact guard. COTA K followed the resident by pushing the wheelchair from behind the resident. However, Resident #9 did not lift his feet high enough and fell forward through the doorway hitting the floor. He was holding onto the rail with his left hand and holding the cane in his right hand. COTA K was unable to catch him, because the wheelchair was in the way. She stated that at that point, a gait belt would not have helped. COTA K said she did not have a gait belt and that she couldn't find one. During an observation on [DATE] at approximately 12: 10 p.m., COTA K and COTA J, Supervisor, demonstrated how the fall occurred. The door frame and door were metal with glass panes. The door was secured open outwardly. A metal railing extended to the left side through both doors. The elevated surface had metal securing strips and lifting your foot was required to walk across the rubber surface. During an interview on [DATE] at approximately 12:40 p.m., COTA J, Supervisor, stated that she had verbally counseled COTA K after the fall regarding the use of a gait belt and that the resident could not walk through the doorway by himself. COTA J stated that COTA K should have sat the resident down in the wheelchair, and COTA K should have pushed the resident through the doorway in his wheelchair. During an observation on [DATE] at approximately 1:30 p.m., Resident #9 was observed sitting in his wheelchair in the backyard of the memory unit participating in an activity. The resident was fully dressed and was wearing house shoes. The right hand was heavily bandaged with a splint and gauze. The resident was wearing a golf cap and was asked if he had an injury to his head. He lifted the brim of the hat and exhibited the laceration with dried blood. He was alert and oriented. Review of the facility's policy dated [DATE] on the use of gait belts revealed that it was the policy that gait belts be used for safety during any mobility . All employees must have a gait belt on them during working hours. Specifically, .5. Any and all ambulation activities. It is the responsibility of all nursing, rehab, and activities personnel working the floor to purchase their own gait bel and maintain it in good, clean condition. 3. Review of Resident 13's admission face sheet dated [DATE] revealed the [AGE] year old resident had been admitted on [DATE] and [DATE] with a medical history of [REDACTED]. Review of a telephone physician's orders [REDACTED]. Review of a quarterly MDS dated [DATE] revealed the resident score a 3 on the BIMS review, indicating severe cognitive deficit and was assessed with [REDACTED]. The MDS also assessed the resident's needs with extensive assistance for bed mobility, transfers and dressing, supervised walking, incontinent of urine and weighing 124 pounds at 62 inches high. Review of a care plan dated [DATE] and updated on [DATE] indicated the resident had the potential to fall related to [MEDICAL CONDITION] medication administration and the potential to wander outdoors. The interventions included observed for fall related to side effects of (dizziness, orthostatic [MEDICAL CONDITION]) usage; and identify times when resident may want to go outdoors and identify staff who can assist the resident outdoors (avoid hot, cold or times weather is not safe or suitable). Review of 2 incident reports dated [DATE] revealed the resident had fallen within the facility while ambulating down the hallway at 9:30 a.m. and was viewed on the monitor from the nurses' station going out into the courtyard at 10:35 a.m. The resident walked down the sidewalk and then turned around to come back under the porch's cover. Instead of entering the door, the resident sat down on the ground and removed her socks and shoes. The staff responded by bringing the resident back into the building. During interview on [DATE] at approximately 3:50 p.m., LVN U, Unit Manager, reported that it was Resident #12's practice to walk outside unsupervised, except by camera. The resident usually walked to the end of the sidewalk, turned left at the corner of the building and reentered from the door at the end of the 600 hall. Staff would release the magnetized door and she would re-enter the building. LVN U stated that on [DATE], she had watched the resident walk down the sidewalk and turned around. At that time, the staff ran to the door to bring her back in. The Unit Manager stated that a resident must be accompanied by a staff member when going out. (The outside temperature at that time according to the local weather was approximately 98 to 100 degrees Fahrenheit.) 4. Review of Resident # 14's admission face sheet dated [DATE] revealed the [AGE] year old resident was admitted on [DATE] and re-admitted on [DATE] with a medical history of [REDACTED]. Review of a care plan dated [DATE] and renewed on [DATE] revealed the resident had an indwelling cardiac pacemaker which was inserted [DATE]. A care plan dated [DATE] and renewed [DATE] revealed the resident had the potential to fall related to unsteady gait, wandering and poor safety awareness related to dementia. An intervention listed was if resident is wandering away from unit, stay with resident, converse and gently persuade resident to walk back to designated area with him Review of a quarterly MDS date [DATE] assessed the resident's BIMS score at 9, indicating moderate cognitive deficit in memory, limited assistance in transfers and ambulation, incontinent of bowel and bladder and requiring limited assistance with hygiene and bathing. The resident used a walker and/or wheelchair for ambulation. His weight was 160 pounds. Review of a facility history and physical dated [DATE] revealed the resident had a history of [REDACTED]. The resident at this time had an indwelling catheter. During an observation on [DATE] at approximately 4:30 p.m. (outside temperature was 100 degrees Fahrenheit according to the local weather report), Resident #14 was attempting to re-enter the main dining room from the back patio and could not keep the metal door open far enough to pull his walker into the room. The resident was struggling and was bleeding from his left elbow. The surveyor intervened and called for help. Staff responded and brought the resident into the room. A few minutes later, it was noted that the metal door frame had a small jagged edge which the staff suspected from how the resident sustained [REDACTED]. On [DATE] at 3:50 p.m., the Administrator and DON were notified of the Immediate Jeopardy (IJ) situation for the above failures and a plan of Removal was requested. The facility began corrective actions on [DATE] at 6:40 p.m. with workmen arranging for the unlocked doors to be magnetically locked, posting staff to sit and monitor the doors while the work was being performed and by in-servicing staff to continue monitoring residents to ensure safety and prevention of leaving the building and falls. The facility's Plan of Removal was provided by the Administrator and DON and was accepted on [DATE] at 3:45 p.m. It included the following steps to be taken by the facility: Action Plan - Global Approach 1. Install Exit sign by door way leading to west courtyard on [DATE] at 12:00 noon. tested at 12:05 and worked. 2. Installed 2nd camera in west courtyard on [DATE] at 7:00 p.m. This additional camera gives full view of the entire courtyard. The feed to the screen (located in front of the nurses' station) flips back and forth every 5 seconds. tested at 7:05 p.m. on [DATE] and it worked. Staff in-serviced on [DATE] about how the new camera system and monitor operated. 3. Started 15-minute staff sweeps of both courtyards on 6:30 p.m. on [DATE] and continued until the camera was installed and the doors were locked. Residents' locations are now checked every 2 hours and as needed per residents' needs. 4. Posted door monitors at both courtyard exits on [DATE] at 6:30 p.m. until maglocks were installed to ensure that no residents got out unattended. Once he maglocks were in place, the door monitors were removed. 5. Audited all care plans (43) of residents located on the secure unit (The Willow) on [DATE] to ensure they were up to date and reflected each residents' care plan was individualized. For example, at risk for falling, wandering outside, special needs and specific needs. 6. In-serviced 100 % staff on following each resident's plan of care on [DATE]. Back-up documentation was incorporated on the CNA assignment sheets so that the CNA can refer to the sheets at all times. Newly assigned and temporary staff (agency) are to be in-serviced during orientation and initial shift. 7. Installed maglock and alarm system on west courtyard on [DATE] at 8:30 p.m. tested at 8:35 p.m. and it worked. All staff (100 %) in-serviced to understand that the new maglocks unlock when the fire system goes off. Currently the facility had 2 doors that can be opened by a switch at the nursing station to exit. In-services were documented, and the system will be put in the QAPI for monitoring and follow-up. 8. Installed maglock and alarm system on the east courtyard door on [DATE] at 10:20 p.m. tested at 10:25 p.m. and it worked. Staff trained on the new system and documented in-service. 9. For both new maglock doors, the facility is discussing putting them on a release switch that would be at the nursing station to allow family members or staff to take residents out on the patio during nice weather time. Currently, the facility has one such door to each courtyard that is tied into this type of switch at the nursing station to allow for exit. 10. In-serviced 100 % staff on responding to doorbell on [DATE]. Back up documentation (assignment sheets) included. Verification of the Plan of Removal: 1. On [DATE] at 2:25 p.m., the Administrator and Director of Physical Environment demonstrated the Exit sign over the west door and demonstrated that the door was locked. All 4 exit doors were demonstrated to be locked. 2. The visibility of the 5 camera monitors located on the wall across from the nurses' station were clear and the first monitor flipped every 5 seconds to reveal the entire back porch and yard on the west side. 3. Eighteen staff members from the day and evening shifts were interviewed to determine was the were in-serviced. Two staff members provided their back-up assignment sheets. The in-service text was reviewed and reflected the updates in staff assignments and actions. The sign-in sheets were reviewed to confirm signatures. 4. Observations were made on [DATE], [DATE] and [DATE] of interactions between staff and residents. Two residents were interviewed and confirmed that they had been told not to open the doors for residents. 5. An extended survey was conducted to determine compliance in other areas of care and services. This included review of a sample of staff personnel files, Employee Misconduct Checks and Criminal History Checks. Contracts were reviewed to determine they were in place. Licensing compliance was also checked to include CLIA waiver, Surety Bond to cover Trust Funds, Emergency Potable Water Supply, signed policies and contracts for outsource services. On [DATE] at 3:

Based on observations, interviews and record reviews, the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct identified quality deficiencies for 3 of 14 residents in the memory care unit (#10, 13 and 14) whose care was reviewed in that: 1. The QA committee, which included the Administrator, DON and Medical Director, did not identify quality deficient practices regarding Residents #10, 13 and 14 who wandered in and out of the building during temperatures of 100 degrees. 2. The QA committee did not develop and implement a plan to prevent incidents such as the fall that resulted in the death of Resident #10 and did not identify getting out into the courtyards as a problem to develop interventions. 3. The QA committee did not review policies/procedures for residents in the memory care unit regarding keeping the residents safe from summer heat waves for the 33 ambulatory residents on the unit. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 7/20/18. While the IJ was removed on 7/22/18, the facility remained out of compliance at s severity level of actual harm with a scope identified as isolated until the secure unit was made safe and the entire staff was in-serviced. These deficient practices could affect 33 residents who were ambulatory and able to wander through the exit doors of the memory unit into the outside gardens and who were at risk for falls, wandering and elopement due to cognitive deficits, lack of coordination, and unsteady gait and could result in deterioration in health, heat stroke and death. The findings were: 1. Review of the facility administrator's personnel file revealed the administrator was hired on 6/12/17 to assure the provision of the best available quality of care for facility residents. The Quality Assessment and Assurance Program encouraged the administration to objectively and systematically monitor and evaluate the quality and appropriateness of resident care on an ongoing basis; to pursue opportunities to improve resident care; to identify problems and to integrate the ongoing operational activities of the medical and management team. Review of the facility investigation report dated 6/5/18 revealed that Resident #10 was found outside of the memory care unit on the ground in the enclosed courtyard on 5/30/18 at approximately 17:15 (5:15 p.m.) in an area that could not be seen by a camera located in the courtyard. The resident was lying in the dirt (rocks), incoherent, twitching, shaking and very warm. The investigation report also revealed that Resident #10 had [MEDICAL CONDITION] her feet and legs from the heat. The resident's internal body temperature was 107.2 degrees. The resident was last seen by the staff between 3:15-3:30 p.m. in the dining room. She got out into the courtyard. She was found at 5:15 p.m. when the staff couldn't find her for dinner. The resident sustained [REDACTED]. Review of a quality assurance meeting agenda conducted on 6//27/18 did not address the circumstances of Resident #10's fall and death from heat stroke and no plans were recommended to ensure a similar incident did not re-occur. During observations on 7/10/18, 7/12/18 and 7/19/18, staff were observed making 15-minute checks of the outside areas where residents wandered in and out of the building. The outside temperatures according to the local weather reports was 95 to 100 degrees Fahrenheit. Residents were not prevented from exiting the building and there was no formalized system in place to inform the staff of the special needs of residents. The monitoring system of residents from the nurses' station was inadequate due to the foggy screens, which prevented residents from being identified. During an interview on 7/20/18 at 6:40 p.m., the Administrator reported that the based on the concerns for safety in the memory unit reported by the surveyor, the facility planned to install a second camera on the west outside courtyard, monitor the exit doors by posting staff to prevent residents from exiting, install magnetic locks (maglocks) to each exit door (2) and audit care plans of residents on the unit to ensure care needs were addressed. Review of a publication dated 2009 and entitled Keeping the Elderly Safe during Summer Heat Waves, recommended that nursing homes go on alert when temperatures rise, and seniors are particularly susceptible to serious health complications from hot weather, including heat exhaustion, heatstroke, sunburns and dehydration. Many seniors are on medications such as diuretics that make them more prone to the burning rays of the sun. Just a short period of time in the sun can cause some major health complications. Heatstroke commonly affects individuals who are debilitated or fatigued. Symptoms include dizziness, weakness, nausea, rapid pulse and a body temperature of more than 102 degrees. Review of a publication dated 2012 entitled Dangers that heat waves pose to seniors, revealed that temperature control centers in the brain become less sensitive with age and may therefore not initiate the correct cooling mechanisms when the body becomes overheated. 2. Review of the job description of the Director of Nurses (DON) issued on 7/13/17 revealed that the DON reported to the Administrator and that the primary responsibility was to ensure the provision of quality of nursing care on a 24-hour basis to the resident .in accordance with Federal, State, Local standards and regulation. The DON develops nursing service objectives, policies and procedures and directs the implementation of these objectives. The DON analyzes and evaluates overall resident care programs; confers with managers and staff concerning problems of resident care and ensures that residents are free from abuse, mistreatment and neglect. The DON also assists the Safety Officer in developing and implementing safety standards for the Nursing Department; and assists the Administrator in the development and implementation of the Quality Assurance and Performance Improvement (QAPI) Program. During an interview on 7/21/18at 3:00 p.m., the DON was asked if the incident on 5/30/18 with Resident #10 was discussed at the 6/27/18 QAPI meeting and if plans had been made to prevent further incidents. The DON reported that the incident was mentioned but was not discussed in detail. No plans were developed to prevent future incidents, except that the staff was required to go outside and look for the presence of residents in the 2 yards every 15 minutes. Review of the QAPI annual agenda dated 6/27/18 listed falls to be discussed in (MONTH) and August. Review of the QAPI policy dated 9/27/17 and signed by the DON, Medical Director and Administrator revealed that the policy was to be updated annually or more often when revision was deemed appropriate by the Quality Assurance Committee. Review of the sign-in sheet dated 6/27/18 listed 19 signatures which included the Administrator, DON, Director of Physical Environment and Medical Director. During the exit conference on 7/23/18 at approximately 5:00 p.m., the DON was asked the question: How long had the facility planned to have the staff continue 15-minute checks of the outside areas of the east and west porches and backyard. The DON responded: Until we came up with a better idea. 3. Review of Resident #10's admission face sheet dated 7/10/18 revealed the [AGE] year old resident was admitted on [DATE] and readmitted on [DATE] with a medical history of [REDACTED]. The resident resided in the Memory/Secure Unit and was discharged on [DATE] to a hospital after an incident. Review of a quarterly MDS dated [DATE] revealed the resident had a BIMS score of 3, indicating severe cognitive deficit, which included inattention and disorganized thinking. Resident #10 was also assessed requiring extensive assistance with transfers, ambulation, dressing, bathing and hygiene and was incontinent of bowel and bladder. The resident weighed 114 pounds and was 59 inches tall. Review of a care plan dated 5/10/18 revealed the resident tended to get out of her wheelchair and walk away unattended. One of the interventions was to place her in an area where frequent observation was possible. The care plan also revealed the resident was at risk for falls related to cognitive deficits and poor safety awareness. The goal for the quarter (5/10/18-8/10/18) was that the resident would not have any injuries from falls. One of the interventions was the use of an alarm while in the wheelchair. On 4/19/18, a care plan documented the resident was assessed with [REDACTED]. Review of nursing notes dated 5/15/18 at 5:55 p.m. revealed Resident #10 had minimal intake appetite and was poor for meal assistance and refused food. When the spoon is taken to the resident's mouth she barely opens or cries out as if she is in pain to eat. Resident has been falling asleep in her plate at the table. Review of a physician's progress report dated 5/27/18 revealed that Resident #10 had complained of pain to areas of her face due to shingles. The shingles had resolved, but the resident had post neuralgia pain. Neurological exam revealed the resident was unable to follow commands, nonsensical speech and confused. Resident #10 had advanced dementia. Further review of nursing notes dated 5/3018 at 5:36 p.m. revealed that at dinner time CNA P alerted this nurse that she was not able to find the resident. This nurse stated that the resident was usually in bed after lunch and the CNA P stated that she was not in the bed. Staff immediately began room to room checks and was in the middle of checking rooms when CNA P had gone outside and reported that the resident was on the ground outside. The resident was unresponsive, was visibly breathing, but not responding to verbal stimuli. Vital signs were: Blood Pressure 102/50 (low); respirations 22 (fast); pulse 125 (fast) breaths per minute (BPM) and her body temperature was 107.4 degrees Fahrenheit. The resident was transported by wheelchair to the shower to wash the dirt off the face, to remove her clothing and to lower the body temperature with a cold shower. The nurse practitioner was notified, and the facility received an order to transport the resident to the ER. The nurse's note also documented on 5/30/18 that Resident is able to ambulate but has been encouraged to use the wheelchair by staff due to chronic pain in knees which causes her gait to be unsteady at times. Resident has been using the wheelchair today for mode of transportation up until this incident. (The outside temperature at 3:30 p.m. on 5/30/18 according to the local weather report was 98 to 100 degrees Fahrenheit.) Review of a hospital record dated 5/30/18 revealed that Resident #10 had been outside on the ground in 100 degree temperature for under 2.5 hours and a laboratory workup revealed rhabdomyolysis (condition in which damaged skeletal muscle tissue breaks down rapidly and damaged muscle cells are released into the bloodstream), urinary tract infection, and severe dehydration. The resident was administered 4 liters of IV fluids and was admitted to ICU for [REDACTED]. The ER report also included a description of the resident having multiple large blisters of both lower extremities and a wound care consult was ordered. The consult documented: Second [MEDICAL CONDITION] large blister involving the dorsum (on top of foot) of both feet and right inner thigh. A CT scan dated 5/30/18 also assessed the resident with exposure to excessive natural heat, urinary infection. (A consult dated 5/31/18 also described the wounds as consistent with 2nd [MEDICAL CONDITION] ordered xeroform to cover all wounds and lightly wrap with kerlix.) The resident was ordered [MEDICATION NAME] 2 mg Q2H per IV for pain on 6/1/18 as well as an antibiotic [MEDICATION NAME] ([MEDICATION NAME]) 1 gm daily. Upon being transferred to Intermediate Care, the family met with the physician to decide to transfer the resident to another nursing facility under hospice care. On 6/3/18, the resident was transferred to another nursing facility under hospice care with a [DIAGNOSES REDACTED]. Review of a statement given at an investigation conducted on 6/2/18 revealed that at approximately 10:10 a.m., LVN N stated that Resident #10 was using a wheelchair on 5/30/18 due to her knees not being stable and from having recently recovered from the flu and shingles. She stated that the resident usually took a nap after lunch, but instead was seen folding towels with other residents in the main dining room. Review of a statement given at an investigation conducted on 6/2/18 revealed that at approximately 11:20 a.m., AD F reported that the resident usually slept through activities but was alert on 5/30/18. (AD F assigned the resident to fold hand towels.) Review of a statement given at an investigation conducted on 6/2/18 revealed that at approximately 11:20 a.m., CNA O stated that she had assumed her duties on 5/30/18 at 7:00 a.m. to 3 :30 p.m. and that Resident #10 was assigned to her. She stated that due to her low cognitive function, the resident wouldn't walk and was slow getting going. She stated that she had taken her to the rest room and changed her and then brought her back to the dining room at 2:30 p.m. She stated that she gave report of the resident's activities to CNA P. She stated that Resident #10 was not strong enough to push open the door to the courtyard and theorized that another resident who usually sat next to the door may have opened it. Review of a statement given at an investigation conducted on 6/2/18 revealed that at approximately 3:35 p. m., CNA P stated that Resident #10 was more active on her shift, because she usually napped in the afternoon. She stated that the resident had not been active before due to the flu and shingles (4/27/18). Review of the facility's completed investigation report dated 6/5/18 revealed the resident was found outside of the building on the ground in the enclosed courtyard on 5/30/18 at approximately 17:15 (5:30 p.m.) in an area that could not be seen by a camera. CNA P's written statement reported that she had found the resident lying in the dirt, incoherent, twitching, shaking and very warm. The investigation report also revealed that Resident #10 had [MEDICAL CONDITION] her feet and legs from the heat. The resident was last seen between 3:15-3:30 p.m. in the dining room. She got out into the courtyard. She was found at 5:15 p.m. when the staff couldn't find her for dinner. She does have injuries. The report also stated that a wheel chair alarm was not in place on the wheelchair that day. Further review of the facility's report revealed a written statement by CNA M that she also had worked on 5/30/18 and upon assuming her shift at 3:30 p.m. had gone around and checked where the residents assigned to her were located on the unit. Resident #10 was not assigned to her on that day. CNA P was assigned to the resident. During a second interview on 7/20/18 at 5:05 p.m., CNA P stated and described in a written statement that she had signed in on 5/30/18 at 2:50 p.m. and received report from CNA O. She stated that she was surprised to see Resident #10 sitting up in a wheelchair. It was not the usual wheelchair that the resident sat in. She spoke to the resident and then proceeded to take care of the other residents assigned to her. CNA P did not see the resident get up and at approximately 5:00 p.m., LVN CC asked CNA P where Resident #10 was. A search of the rooms was initiated, and CNA P found the resident outside of the building. The resident was wearing pants and a shirt. During an observation on 7/10/18 at 11:15 a.m., and standing in the dining room, the courtyard could be observed through 3 large panes of glass. Two of them were windows and the third was a metal door. The right side of the courtyard where the fence and building joined created a blind spot that could not be observed by looking out of the windows. There was no exit sign above the door and when pushed opened, a bell rang at the nurses' station. A fire alarm pull system was located next to the door. Stepping into the courtyard, the blind spot could be observed on the right side of the building. A camera was posted in the corner of the overhead and was pointing away from the blind spot. Stepping back into the building, the bell sounded again. Standing at the nurses' station, 5 monitors were noted located on the wall in front of the nurses' station. The monitor corresponding to the camera on the porch was pointed directly ahead and did not pick up the blind spot. Each time the door opened, the bell sounded. During an interview on 7/10/18 at approximately 1:55 p.m., the Director of Nurse stated that on 5/30/18, the day of Resident #10's incident, there was a lot of activity on the memory unit including physician visits and that it was difficult for the staff to keep track of all the residents on the unit. When the door to the backyard was opened, a bell rung at the nurses' station. The Director of Nurses was asked if anyone on the unit had heard the bell sound when Resident #10 exited. The Director of Nurses stated that she didn't not know. When asked if she felt the unit was safe, she stated that she thought so. The Director of Nurses reported that she started 15-minute staff sweeps of both courtyards on 5/30/18 at 6:30 p.m., in addition to monitoring the camera feeds, and directed the staff to document the observations on a log maintained at the nurses' station. During the same interview on 7/10/18 at approximately 1:55 p.m., the Director of Physical Environment was asked why the camera outside the door to the courtyard was not turned towards the blind spot in the courtyard after Resident #10 had fallen. He stated that doing so would prevent the nurses at the nurse's station from monitoring the rest of the courtyard. He stated that a second camera had been ordered and received but the facility had not installed the camera yet. During an interview on 7/10/18 at 11:20 a.m., AD F stated that she had placed Resident #10 at a table to fold towels along with other residents and at 3:30 p.m. she had clocked out of the facility. When asked who was assigned to continue monitoring the activity, she stated that there was another AD (I) on the unit until 5:30 p.m. During an interview on 7/12/18 at 11:30 a.m., AD I stated that she had worked on the memory unit on 5/30/18 and was involved with other residents in the independent dining room and could not see Resident #10 from her location. She stated that she was not able to see the residents folding towels, that she was busy with other residents and that there were few residents up at that time; and that there were other staff on the unit during the time Resident #10 exited the building. During an interview on 7/20/18 at approximately 4:11 p.m., Resident #10's daughter reported that the resident had been in the facility for 3 years and had passed away on 6/9/18. She stated that during multiple visits during the week by family members, the resident could not recognize who they were. She stated that she did not believe that the resident had opened the door to the courtyard because she was so tiny. She believed someone else had opened it for her. She stated that she had seen [MEDICAL CONDITION] that they were awful sight to see. She stated that the resident [MEDICAL CONDITION] her elbow as well. The daughter stated that the family had ordered an autopsy because she didn't feel the death was natural. She also stated that the facility needed to lock that door and not let anyone out unsupervised. During interviews on 7/20/18 at approximately 6:00 p.m., Residents 15 and 16 stated that they generally sit next to the door in the main dining room and had both been counseled not to open the door to let residents outside to the courtyard. Both residents recalled the incident with Resident #10 but denied opening the door for her. During an interview on 7/22/18 at 2:50 p.m., LVN U, Unit Manager, was asked how long had the facility planned to have the staff continue 15 minutes checks (staff sweeps of both courtyards in addition to monitoring the camera feeds) of the outsides of the east and west porch and backyard. LVN U stated that it would continue until we come up with a better idea. During an interview on 7/23/18 at approximately 10:30 a.m., the pathologist conducting the autopsy stated that there was no question that heat stroke contributed to Resident #10's death due to the fall and lying outside. During the exit conference on 7/23/18 at approximately 5:00 p.m., the DON was asked the question how long had the facility planned to have the staff continue 15-minute checks of the outsides courtyards, and responded: until we came up with a better idea. Review of a publication dated 2009 and entitled Keeping the Elderly Safe during Summer Heat Waves, recommended that nursing homes go on alert when temperatures rise, and seniors are particularly susceptible to serious health complications from hot weather, including heat exhaustion, heatstroke, sunburns and dehydration. Many seniors are on medications such as diuretics that make them more prone to the burning rays of the sun. Just a short period of time in the sun can cause some major health complications. Heatstroke commonly affects individuals who are debilitated or fatigued. Symptoms include dizziness, weakness, nausea, rapid pulse and a body temperature of more than 102 degrees. Review of a publication dated 2012 entitled Dangers that heat waves pose to seniors, revealed that temperature control centers in the brain become less sensitive with age and may therefore not initiate the correct cooling mechanisms when the body becomes overheated. 4. Review of Resident 13's admission face sheet dated 7/20/18 revealed the [AGE] year old resident had been admitted on [DATE] and 1/12/18 with a medical history of [REDACTED]. Review of a telephone physician's orders [REDACTED]. Review of a quarterly MDS dated [DATE] revealed the resident score a 3 on the BIMS review, indicating severe cognitive deficit and was assessed with [REDACTED]. The MDS also assessed the resident's needs with extensive assistance for bed mobility, transfers and dressing, supervised walking, incontinent of urine and weighing 124 pounds at 62 inches high. Review of a care plan dated 1/26/18 and updated on 7/21/18 indicated the resident had the potential to fall related to [MEDICAL CONDITION] medication administration and the potential to wander outdoors. The interventions included observed for fall related to side effects of (dizziness, orthostatic [MEDICAL CONDITION]) usage; and identify times when resident may want to go outdoors and identify staff who can assist the resident outdoors (avoid hot, cold or times weather is not safe or suitable). Review of 2 incident reports dated 7/13/18 revealed the resident had fallen within the facility while ambulating down the hallway at 9:30 a.m. and was viewed on the monitor from the nurses' station going out into the courtyard at 10:35 a.m. The resident walked down the sidewalk and then turned around to come back under the porch's cover. Instead of entering the door, the resident sat down on the ground and removed her socks and shoes. The staff responded by bringing the resident back into the building. During interview on 7/21/18 at approximately 3:50 p.m., LVN U, Unit Manager, reported that it was Resident #12's practice to walk outside unsupervised, except by camera. The resident usually walked to the end of the sidewalk, turned left at the corner of the building and reentered from the door at the end of the 600 hall. Staff would release the magnetized door and she would re-enter the building. LVN U stated that on 7/13/18, she had watched the resident walk down the sidewalk and turned around. At that time, the staff ran to the door to bring her back in. The Unit Manager stated that a resident must be accompanied by a staff member when going out. (The outside temperature at that time according to the local weather was approximately 98 to 100 degrees Fahrenheit.) 6. Review of Resident # 14's admission face sheet dated 12/27/17 revealed the [AGE] year old resident was admitted on [DATE] and re-admitted on [DATE] with a medical history of [REDACTED]. Review of a care plan dated 12/28/17 and renewed on 3/28/18 revealed the resident had an indwelling cardiac pacemaker which was inserted 6/1/04. A care plan dated 12/27/17 and renewed 5/8/18 revealed the resident had the potential to fall related to unsteady gait, wandering and poor safety awareness related to dementia. An intervention listed was if resident is wandering away from unit, stay with resident, converse and gently persuade resident to walk back to designated area with him Review of a quarterly MDS date 4/29/18 assessed the resident's BIMS score at 9, indicating moderate cognitive deficit in memory, limited assistance in transfers and ambulation, incontinent of bowel and bladder and requiring limited assistance with hygiene and bathing. The resident used a walker and/or wheelchair for ambulation. His weight was 160 pounds. Review of a facility history and physical dated 6/12/18 revealed the resident had a history of [REDACTED]. The resident at this time had an indwelling catheter. During an observation on 7/20/18 at approximately 4:30 p.m. (outside temperature was 100 degrees Fahrenheit according to the local weather report), Resident #14 was attempting to re-enter the main dining room from the back patio and could not keep the metal door open far enough to pull his walker into the room. The resident was struggling and was bleeding from his left elbow. The surveyor intervened and called for help. Staff responded and brought the resident into the room. A few minutes later, it was noted that the metal door frame had a small jagged edge which the staff suspected from how the resident sustained [REDACTED]. On 7/20/18 at 3:50 p.m., the Administrator and DON were notified of the Immediate Jeopardy (IJ) situation for the above failures and a plan of Removal was requested. The facility began corrective actions on 7/20/18 at 6:40 p.m. with workmen arranging for the unlocked doors to be magnetically locked, posting staff to sit and monitor the doors while the work was being performed and by in-servicing staff to continue monitoring residents to ensure safety and prevention of leaving the building and falls. The facility's Plan of Removal was provided by the Administrator and DON and was accepted on 7/22/18 at 3:45 p.m. It included the following steps to be taken by the facility: Action Plan - Global Approach 1. Install Exit sign by door way leading to west courtyard on 7/21/18 at 12:00 noon. tested at 12:05 and worked. 2. Installed 2nd camera in west courtyard on 7/20/18 at 7:00 p.m. This additional camera gives full view of the entire courtyard. The feed to the screen (located in front of the nurses' station) flips back and forth every 5 seconds. tested at 7:05 p.m. on 7/20/18 and it worked. Staff in-serviced on 7/2/18 about how the new camera system and monitor operated. 3. Started 15-minute staff sweeps of both courtyards on 6:30 p.m. on 5/30/18 and continued until the camera was installed and the doors were locked. Residents' locations are now checked every 2 hours and as needed per residents' needs. 4. Posted door monitors at both courtyard exits on 7/20/18 at 6:30 p.m. until maglocks were installed to ensure that no residents got out unattended. Once he maglocks were in place, the door monitors were removed. 5. Audited all care plans (43) of residents located on the secure unit (The Willow) on 7/20/18 to ensure they were up to date and reflected each residents' care plan was individualized. For example, at risk for falling, wandering outside, special needs and specific needs. 6. In-serviced 100 % staff on following each resident's plan of care on 7/21/18. Back-up documentation was incorporated on the CNA assignment sheets so that the CNA can refer to the sheets at all times. Newly assigned and temporary staff (agency) are to be in-serviced during orientation and initial shift. 7. Installed maglock and alarm system on west courtyard on 7/20/18 at 8:30 p.m. tested at 8:35 p.m. and it worked. All staff (100 %) in-serviced to understand that the new maglocks unlock when the fire system goes off. Currently the facility had 2 doors that can be opened by a switch at the nursing station to exit. In-services were documented, and the system will be put in the QAPI for monitoring and follow-up. 8. Installed maglock and alarm system on the east courtyard door on 7/20/18 at 10:20 p.m. tested at 10:25 p.m. and it worked. Staff trained on the new system and documented in-service. 9. For both new maglock doors, the facility is discussing putting them on a release switch that would be at the nursing station to allow family members or staff to take residents out on the patio during nice weather time. Currently, the facility has one such door to each courtyard that is tied into this type of switch at the nursing station to allow for exit. 10. In-serviced 100 % staff on responding to doorbell on 7/2/18. Back up documentation (assignment sheets) included. Verification of the Plan of Removal: 1. On 7/21/18 at 2:25 p.m., the Administrator and Director of Physical Environment demonstrated the Exit sign over the west door and demonstrated that the door was locked. All 4 exit doors were demonstrated to be locked. 2. The visibility of the 5 camera monitors located on the wall across from the nurses' station were clear and the first monitor flipped every 5 seconds to reveal the entire back porch and yard on the west side. 3. Eighteen staff members from the day and evening shifts were interviewed to determine was the were in-serviced. Two staff members provided their back-up assignment sheets. The in-service text was reviewed and reflected the updates in staff assignments and actions. The sign-in sheets were reviewed to confirm signatures. 4. Observations were made on 7/20/18, 7/21/18 and 7/22/18 of interactions between staff and residents. Two residents were interviewed and confirmed that they had been told not to open the doors for residents. 5. An extended survey was conducted to determine compliance in other areas of care and services. This included review of a sample of staff personnel files, Employee Misconduct Checks and Criminal History Checks. Contracts were reviewed to determine they were in place. Licensing compliance was also checked to include CLIA waiver, Surety Bond to cover Trust Funds, Emergency Potable Water Supply, signed policies and contracts for outsource services. On 7/22/18 at 3:45 p.m., the Administrator and DON were informed that the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. The facility identified on 7/12/17

Based on observations, record review and interviews, the facility failed to provide a safe, clean and homelike environment to 4 of 7 residents (#2, 6, 9 and 12) 4 of 5 rooms (#509, 507, 505, 503) reviewed for cleanliness and vermin in that: 1. Residents #2, 6, 9 and 12 had packaged terminal air conditioners (PTAC) wall units in their rooms with outtake grills on the top of the units covered with rust, dried sediment from water condensation and peeling paint. The bottoms of the units (intake) had metal/or paper filters that were coated with dust, torn or lying on the floor. The floors had accumulated dirt, grime (dirt ingrained on the surface), dust, paper particles and food. 2. The toilet plunger in the bathroom of room [ROOM NUMBER] was located on the floor next to the toilet. 3. The facility did not have a schedule for terminally cleaning the beds and rooms of residents resulting in bed frames and side rails having accumulated dust. These failures to maintain the sanitary conditions of the rooms could affect the respiratory status and health conditions of 6 elderly residents. The findings included: 1. During an interview on 7/10/17, at approximately 9:30 a.m., the Director of Physical Environment, reported that the facility had a pest control contract and that the facility was treated weekly. The Director provided a copy of the contract, a log sheet of visits and several invoices and agreed to participate in observations rounds of rooms with potential vermin infestation. Review of the contract confirmed what the Director had reported, and the log indicated that on 2/21/18, the contractor had responded to a report by Resident #6 of a mouse/rat in room [ROOM NUMBER]. Review of Resident #6's admission face sheet dated 7/10/18 revealed the resident was admitted on [DATE] with a medical history of [REDACTED]. During an initial observation tour on 7/10/18 at approximately 10:05 a.m., the PTAC unit in room [ROOM NUMBER] was assessed for possible holes and openings for mice or rats. The grill on top of the unit that provided air to the room was rusted, with peeling paint and was covered with dried minerals from condensation. The bottom of the unit had a paper filters that was partially on the floor. The floor had accumulated dirt, dust, paper particles and food. The observations were pointed out to the Director of Physical Environment. On 7/10/18 at 10:05 a.m., Resident # 6 was lying in bed at the time and reported that she had seen a mouse, or rat, on the floor under the PTAC unit. During an observation on 7/10/18 at approximately 10:10 a.m., Resident #12 was observed sitting up in a wheelchair in room [ROOM NUMBER]. She was alert and oriented to herself and was wearing nonskid socks. A PTAC unit was running and had a rusted grill cover that was peeling paint and covered with dried sediment from water condensation. The bottom of the unit was open, and the floor had accumulated dirt, dust and grime. The air filter was metal. The observation was confirmed by the Director of Physical Environment. Review of Resident #9's admission face sheet dated 7/10/18 revealed the resident was admitted on [DATE] with [MEDICAL CONDITION], muscle weakness and atrophy, and abnormal gait and mobility, dysphagia, lack of coordination and unspecified head injury, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of a quarterly MDS dated [DATE] assessed the Resident #9's BIMS score as 5, indicating severe cognitive deficit, requiring limited assistance in transfers, an inability to walk, total assistance with hygiene and bathing, at risk for falls and incontinent of bowel and bladder. The resident was also assessed for continuous use of oxygen therapy. During an observation on 7/10/18 in room [ROOM NUMBER] at approximately 10:15 a.m., the grill on top of the PTAC unit in room [ROOM NUMBER], that provided air to the room was rusted, had peeling paint and was covered with dried sediment from water condensation. The bottom of the unit was open, and the floor had accumulated dirt, dust and grime. An oxygen concentrator with a nasal cannula was switched to the on position and was running, although resident (#9) was not in the room. The condition of the PTAC was confirmed by the Director of Physical Environment. Review of Resident #2's admission face sheet dated 7/10/18 revealed the resident had been admitted to the facility on [DATE] with a medical history of [REDACTED]. Review of a nursing admission note dated 6/17/18 revealed Resident #2 had been admitted from another nursing facility and was weak, had intermittent confusion and had recently been discharged from an alcohol rehabilitation center. On 6/29/18, the resident was started on an antibiotic for a urinary tract infection. During an observation on 7/10/18 in room [ROOM NUMBER] at approximately 10:20 a.m., Resident # 2 was met at the doorway of her room (503) and she complained that the room was dirty. The grill on top of the PTAC unit, that provided air to the room was rusted, had peeling paint and was covered with dried sediment from water condensation. The bottom of the unit was open, and the floor had accumulated dirt, dust and grime and a used paper towel. The coils inside the unit were also coated with white and black matter that appeared to be minerals and mole. The metal filter on the bottom of the unit had several large holes and was lying on the floor under the unit. The window pane of the left side of the window had a large smudge that appeared ingrained in the glass and needed replacing. The observation was confirmed by the Director of Physical Environment. 2. During an observation on 7/10/18 at approximately 10:15 a.m., a toilet plunger had been placed on the floor next to the toilet in room [ROOM NUMBER]. The plunger was not inside a container, holder or plastic bag to prevent contamination. 3. During an observation on 7/10/18 at approximately 10:20 a.m., the side rails and bed frames in the occupied beds in rooms 503, 505 and 509 were noted to have accumulated amounts of dust. During an interview on 7/10/18 at approximately 10:20 a.m., the Director of Physical Environment was asked if the facility housekeeping department had a schedule to perform terminal/deep cleaning of rooms and bed frames of occupied beds to remove accumulated dust. The Director stated that there was no schedule and that the rooms and beds were deep cleaned when the residents were discharged . During an interview on 7/22/18 at approximately 2:40 p.m., the weekend floor tech supervisor reported that he had heard that a new deep cleaning of room schedule was being talked about but had not been set up yet. He stated that the rooms were deep cleaned when a resident was discharged . He also reported that he had not received a work requests to clean the bottom areas of the air conditioners of the units in the 500 halls but would address those areas immediately with the housekeepers. Information provided by the facility on 7/10/18 revealed there were six residents in 4 bedrooms in Hall 500 in rooms 509, 507, 505 and 503.