Every finding on record at Galveston Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen in that: 1. One container of macaroni salad with plastic wrap not properly sealed, dated 07/09/26 - 07/12/26, located in refrigerator #1. 2. One container of potato salad with plastic wrap not properly sealed, dated 07/06/26 - 07/09/26, located in refrigerator #2. 3. One container of hard-boiled eggs dated 07/06/26 - 07/09/26, hot dog [NAME] dated 07/03/26 - 07/06/26, and a container of red sauce dated 07/09/26 - 07/12/26, located in refrigerator #2 indicating these food items should have been removed prior to surveyor entrance date of 07/13/26. 4. The facility failed to maintain the stove area, countertops, and food preparation area in a clean and sanitary manner. These failures could affect all residents in the facility who eat from the kitchen, by placing them at risk of contracting food borne illnesses. Findings included: Interview and observation on 07/13/26 at 8:14 AM during the initial tour of the kitchen with [NAME] H revealed the kitchen floor was wet with water, food, and trash. Food crumbs were observed on the stove area and unclean countertops. In the dishwashing area, there were dirty dishes piled at the sink area. Further observations revealed there was a container of macaroni salad dated to be removed on 07/12/26 in refrigerator #1, container of potato salad dated 07/09/26, and hard boiled eggs dated 07/09/26, hot dog [NAME] dated 07/06/26, and a container of red sauce dated 07/12/26, located in refrigerator #2. According to [NAME] H, he did not complete a walk through this morning and tray aides were responsible for completing daily walk throughs to remove any outdated food containers. [NAME] H stated not removing outdated food items placed risk of bacteria growing, which could cause food to become contaminated and residents to become ill. During an interview and observation with the Dietary Manager on 07/14/26 at 9:30 AM, the Dietary Manager stated it was the responsibility of all kitchen staff to date and label food if they open them. The Dietary Manager stated that all food should be labeled with the date it was opened and a use by date if applicable. The Dietary Manager stated that not dating, labelling, and properly sealing food placed residents at risk of being served unsafe food. The Dietary Manager stated she completed a walk through daily and expected the staff to do the same and remove anything was outdated so it would not be served to residents. The Dietary Manager stated she was notified by [NAME] H that the kitchen was in disarray and had not been cleaned over the weekend. According to Dietary Manager, she expected staff to maintain a healthy, clean environment to store and prepare meals. In an interview on 07/14/26 at 4:27 PM, the Administrator stated she expected all staff to follow policy and procedure on keeping the cleanliness of the kitchen. According to the Administrator, when she started there was a lot of broken equipment and the kitchen was not kept very well. The Administrator stated that now there was a deep cleaning schedule and expectations to clean spills, crumbs, keep the floors swept and mopped, wearing hair nets and providing presentable food for residents. The Administrator stated that all food should be properly sealed, dated, and labeled; not doing so placed residents at risk of food borne illnesses. The Administrator stated the Dietary Manager was responsible for ensuring this was being done. Record review of the facility's current, undated Food Receiving and Storage policy reflected the following: Foods shall be received and stored in a manner that complies with safe food handling practices.Refrigerated/Frozen Storage1. All foods in the refrigerator are covered, labeled, and dated ( use by date) .7. Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.

Based on interview and record review revealed the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that were readily accessible for Resident 4 of 6 (Resident #6, #20, #24 and #47) reviewed for clinical records. 1. The facility failed to ensure that consultant pharmacist medication regimen review was kept in residents' active clinical records for Resident #6, #24 and #47 after the facility underwent a change of partnership.2. The facility failed to ensure the medical records for Resident #20 included his code status. This failure placed residents at risk of not having access to their records or receiving thorough HHSC investigations of complaints.Findings includedFindings included:1.In an interview on [DATE] at 9:11 a.m. the Operational Manager was asked to provide Pharmacist Report/Drug Regimen Review for the last 12 months. Record review of facility Pharmacy binder revealed it only contained [DATE] through [DATE] Consultant Pharmacist's Medication Regimen Review. Further review revealed [DATE]- [DATE] were not provided, unable to review pharmacy review for Resident #6, Resident #24 and Resident #47.Interview on [DATE] at 6:08 p.m. the DON stated the only consultant pharmacist medication regimen review on file would be from [DATE]. She stated she does not have any pharmacy recommendations prior to [DATE]. She stated the previous facility team took everything before the new company took over in [DATE]. Interview on [DATE] at 6:10 p.m. the Operations Director stated the previous facility took most of the paper documents with them. She stated it happened before she was employed on [DATE]. She stated attempts were made to obtain documents but were unsuccessful. She stated she was aware files needed to be kept for a while. She stated the potential risk of not keeping documents on file would be the facility would be unable to track any concerns or changes within the residents. Interview on [DATE] at 6:46 p.m. the Administrator stated the previous company took all paper documents with them. He stated a lot of things were missing and attempts were made to obtain them but were unsuccessful. He stated files should be kept for years. He stated they had no control of what the previous company took. He stated the facility only had the residents' electronic health records but no paper documents prior to [DATE]. 2. Record review of Resident #20's discharge MDS Assessment, dated [DATE], revealed a [AGE] year-old male who admitted to the facility on [DATE] and discharge [DATE]. Resident #20 had diagnoses which included spinal stenosis, lumbar region with neurogenic claudication (narrowing of the lower spinal canal, compressing nerve roots), and Type 2 diabetes mellitus without complication (sustained high blood sugar levels). The MDS reflected that the residents' cognition was moderately impaired with a BIMS score of 12. Record review of Resident #20's care plan, revised [DATE], reflected the care plan did not address the resident's code status. Record review of Resident #20's [DATE] physician's orders, revealed no physician's order for code status, such as full code status or DNR. Interview on [DATE] at 12:02 p.m., Resident #20 stated he was doing well. Resident #20 stated he could not recall whether he was a full code or DNR. He stated it was something he would have to think about.Interview on [DATE] at 3:06 p.m., RN C stated he was the nurse assigned to Resident #20 before his discharge on [DATE]. RN C stated each resident should have a code status. He stated the admission nurse should document the resident's code status, full code or DNR, in the clinical records. RN C reviewed Resident #20's clinical records and stated Resident #20 did not have an order for a code status or was care plan for it. He stated the MDS Coordinator was responsible for updating care plans. He stated he was not aware Resident #20 did not have a code status. RN C stated the potential risk of not having a code status would be resident coding and staff would not know whether to resuscitate him or not.Interview on [DATE] at 3:25 p.m., the ADON stated each resident in the facility should have a code status. She stated the admission nurse was responsible for obtaining a code status. The ADON reviewed Resident #20's clinical record and stated Resident #20 did not have an order or care plan for it. She stated she was not aware there were no orders in place for Resident #20's code status. She stated the MDS Coordinator was responsible for updating care plans. The ADON stated if the resident did not have an out of hospital DNR they would be full code. She stated there would be no potential risk because the nurses would perform CPR if no DNR was in place. Interview on [DATE] at 5:32 p.m. the MDS Coordinator stated she was responsible for completing and updating comprehensive care plans. The MDS Coordinator stated residents' code status should be care planned. She stated care plans should reflect the residents' code status. She reviewed Resident #20's physician's order and stated the reason why Resident #20's code status was not care planned was due to the resident not having an order for it. She stated she was not aware Resident #20 did not have a code status. Interview on [DATE] at 6:06 p.m., the DON stated she was not aware Resident #20 did not have a code status. She stated it was the responsibility of the admitting nurse or the Social Worker to obtain a code status and include it the resident records. The DON stated if no code status was obtained the resident would be considered full code and might not reflect his wishes.Record review of facility Retention of Medical Record, dated 12/2006 reflected the following: Medical records shall be retained by the facility in accordance with current applicable laws. 1.Medical records of discharged residents will be retained for a period of 7 years. In case of minors, records shall be retained for not less than 10 years after the resident reaches legal age as established by this state.

Based on observation, interview, and record review the facility failed to maintain all mechanical and electrical equipment in safe operating condition by failing to maintain the dishwasher in safe operating condition. The facility failed to ensure the dishwasher in the facility's only kitchen was cleaned, disinfected and reached minimum 120 degrees during wash and rinse cycles when the Dishwasher Aide was cleaning breakfast dishes on 7/13/26. These failures could place residents at risk of foodborne illness.Findings included: Record review on 07/13/26 at 9:30AM of Dish Machine Temperatures and Sanitizing Log dated July 2026 revealed dates 07/01/26 - 07/12/26 documented 120 for wash/120 rinse/200 parts per million for AM, Noon, and PM wash. Further review of the log revealed date 07/13/26 AM and PM logs were already filled out with 120 for wash/120 rinse/200 parts per million for AM and Noon. Interview and observation on 07/13/26 at 8:31 AM upon arrival to the kitchen revealed the Dishwasher Aide G placing breakfast dishes in the dishwasher. Observation of the dishwasher running at 109 degrees with white substance built up and bubbling in the water at the dispensing spout. Dishwasher Aide G expressed that she did not know what the white substance was that was gathered in the water. Dishwasher Aide G stated she was aware the dishwasher ran at a minimum of 120 degrees. When Dishwasher G was asked what was the procedure for washing dishes, she did not respond. Interview and observation on 07/13/26 at 9:24 AM, [NAME] H revealed when he returned to work on 07/13/26 at 5:30 AM he noticed the kitchen in disarray. According to [NAME] H, Dishwasher Aide G was responsible for dishes today, and to ensure the dishwasher was running properly. [NAME] H stated he could not identify the white substance bubbling in the water and building up at the dispensing spout. [NAME] H stated he was aware the dishwasher was to run at a minimum of 120 degrees consistently, and when staff would need to allow the dishwasher to run a few times to allow the temperature to set at 120 degrees. [NAME] H stated not allowing the temperature to reach 120 degrees before starting the dishes placed residents at risk of eating off dirty dishes, which could cause spread of infection. Interview and observation on 07/13/26 at 9:45 AM with the Maintenance Director revealed he has not had any issues with the dishwasher reaching up to 120 degrees, during his monthly inspections. The Maintenance Director stated today was the first day of hearing there was an issue, he would adjust the water temperature to allow hot water to flow to the dishwasher. According to the Maintenance Director it was important for the kitchen to have hot water to keep a clean kitchen. During an interview and observation with the Dietary Manager on 07/14/26 at 9:30 AM, the Dietary Manager The Dietary Manager stated she ran the dishwasher and did not have any issues getting the temperature to read at 132 degrees, however during the observation of 5 cycles observation revealed the temperature reaching up to 114 degrees. According to the Dietary Manager the Maintenance Director adjusted the water temperature on 07/13/26 and there were no issues afterwards. During the observation, the Dietary Manager stated she was going to have the dishwasher serviced, as it should not take 5 cycles to reach 120 degrees. The Dietary Manager stated she re-educated the dishwashing staff on ensuring the dishwasher temperature maintained at least 120 degrees while washing the dishes, not doing so placed residents at risk of food borne illness and contamination. In an interview on 07/14/26 at 4:27 PM, the Administrator stated she expected all staff to follow policy and procedure on keeping the cleanliness of the kitchen, not doing so placed all residents and staff at risk of food borne illness and their safety. According to the Administrator, when she started there was a lot of broken equipment and the kitchen was not kept very well. Record review of facility's undated policy titled Dishwashing Machine Use, reflected Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or Part Per Million are adjusted. Record review of manufacturer's Machine Washing revealed the following: Load the Dish machine Properly - Avoid overlapping or overcrowding that can prevent water from reaching all surfaces.Make Sure the Machine is Functioning Properly - A malfunctioning or improperly maintained machine that fails to clean tableware adequately can increase the risk of cross-contamination the next time it comes into contact with food or beverages. To help ensure that your machine functions as it should to effectively clean dishes and destroy harmful microorganisms, perform these steps: 1. CHECK THE GAUGES and compare their readings with the minimum temperatures, chemical concentrations and pressure measurements listed on the data plate: High-temperature, or heat-sanitizing, machines will show a minimum rinse temperature of 180 F and minimum wash temperatures of 150 F, 155 F or 160 F, depending on machine type and make and model. Low-temperature, or chemical-sanitizing machines, also show minimum rinse and wash temperatures - typically 120 F for both - on the data plate. Chemical sanitizing machines also indicate a minimum active concentration of the sanitizer on the data plate.Pressure readings: Not all machines, including those that have a pumped rinse, have a pressure gauge. For those that do, ensure that pressure readings are close to the optimal 20 PSI. 2. CLEAN WASH ARMS AND RINSE JETS FREQUENTLY. Over time, wash arms and rinse jets can become blocked or clogged, either with food debris, sediment, or mineral scale buildupLuckily, wash arms and rinse jets are EASY TO REMOVE for cleaning. Do so often. 3. DE-LIME. If left unchecked, lime buildup will bog down your dish machine. In fact, just 1/4 of lime scale can cause a heating element to use 39 percent more energy.3 Regular de-liming can reduce your water and energy use dramatically.

Based on observations, interviews, and record review the facility failed to equip privacy curtains to ensure full visual privacy for each resident in 5 rooms (Rooms 114, 301, 303, 307, and 402) of 20 rooms reviewed for privacy. The facility failed to ensure residents in Rooms 114, 301, 303, 307, and 402 had privacy curtains in place to ensure full visual privacy. This failure could place residents at risk of being exposed to people in the hallway during procedures when they are exposed. Findings includedObservation and interview on 07/13/26 at 10:25 AM revealed room [ROOM NUMBER] was a double room with one resident in residence. Both beds had the track for ceiling suspended curtains to be installed, however there was no privacy curtain present. The resident did not know how long it had been like that. Observation on 07/13/26 at 10:31 AM revealed room [ROOM NUMBER] was a double room with two residents in residence. The W bed had tracks and clips for ceiling suspended curtains however there was no privacy curtain in place. Observation and interview on 07/13/26 at 10:46 AM revealed room [ROOM NUMBER] was a double room with two residents in residence. The D bed had tracks for ceiling suspended curtains, however there was no privacy curtain, The resident stated it had been that way for months. The W bed had a curtain that provided partial privacy. The resident of the W bed did not like having the end of his bed exposed. Observation on 07/14/26 at 9:35 AM revealed room [ROOM NUMBER] was a double room with one resident in residence. Both beds had tracks for ceiling suspended curtains, but no curtains were in place. Observation on 07/14/26 at 10:05 AM revealed room [ROOM NUMBER] was a double room with one resident in residence. Both beds had tracks for ceiling suspended curtains, however there was no privacy curtain in place. Observation on 07/15/26 from 12:35-12:45 PM revealed Rooms 114, 301, 303, 307, and 402 continued to not have privacy curtains in place. Interview on 07/15/26 at 1:00 PM Housekeeper-F stated she did not know who was responsible for replacing the privacy curtains. She thought it would be Maintenance. Interview on 07/15/26 at 1:32 PM the Director of Plant Operations stated he would hang any privacy curtain he was asked to, but he relied on nursing staff and housekeeping to let him know when they were needed. Interview on 07/15/26 at 1:44 PM the DON did not know for sure who was responsible for privacy curtains, she had been in her position for a short time, but she assumed nursing staff would notify housekeeping when a privacy curtain needed to be replaced because it was dirty. She thought housekeeping should notice if a curtain was simply missing, and maintenance needed to be notified when a curtain needed to be hung. Review of the facility's guidance Resident Room Privacy, undated, reflected: All resident rooms must be arranged and maintained to protect resident privacy and dignity. The facility will use cubicle curtains, screens, and/or other approved procedures to provide full visual privacy during care, treatment, dressing, and other personal activities. For rooms with more than one resident, each bed must have a privacy curtain that allows complete visual separation between residents. In private rooms, the ceiling-suspended curtain requirement does not apply, but the facility must still ensure privacy through other appropriate means.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 8 of 8 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings.This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included:During am observation and a confidential resident group interview with eight residents on 07/14/26 beginning at 10:00 AM, revealed the facility arranged for the meeting to be held in an open activity area in the hallway located near the Business Office, MDS Office and outside the Therapy Gym. There were no doors that could be closed to ensure the residents' privacy during the meeting. The Activity Director did not place any signs to indicate a resident council meeting was in progress. During the meeting, staff were observed walking through the area while the meeting was in progress and volunteers were doing a walk-through. The eight residents in attendance all reported that their monthly resident council meetings were held in the open activity area after 2PM when therapy was gone. The residents stated they knew it was a private meeting; however, no one had offered a private room before and they never thought about asking for one. The residents stated they were used to the open area in the activity area. The residents denied expressing their concern about the location.Interview on 07/14/26 at 11:24 a.m., the Activity Director stated she was responsible for coordinating resident council meetings monthly. She stated resident council meetings were conducted in the activity area. She stated resident council meetings were held at 2PM, to avoid conflicts with therapy sessions and minimize disruptions caused by residents and staff entering and exiting the therapy gym. The Activity Director stated she was aware resident council meetings needed to be in a private setting; however, the facility did not have a room big enough to allow that. The Activity Director stated she would usually post signs on the hallway stating Resident Council Meeting in session; however, she forgot to post them today (07/14/26). She stated she sent out a message to the facility staff and verbally told staff that a resident council meeting was being held. The Activity Director stated residents had the right to have a private meeting; however, there was no potential risk if the residents did not have a private area. Interview on 07/15/26 at 6:37 p.m. the Operations Director stated the Activity Director was responsible for arranging resident council meetings. She stated she was aware resident council meetings needed to be held in a private area. She stated resident council meetings had been held in the activity area; however, they had been exploring options to find a better place for resident council meetings. The Operations Director stated the potential risk of not holding resident council meetings in a private setting would be a violation of resident's privacy, a grievance might want to be reported privately. Record review of facility Resident Council revised 12/2025, reflected the following: The facility supports residents' rights to organize and participate in the resident council.4. The resident council group is provided with space, privacy, and support to conduct meetings.

Based on observations and interviews the facility failed to maintain an effective pest control program to keep the facility free of roaches for 1 (Resident #35) of 5 residents rooms reviewed for pest control. The facility failed to ensure Resident #35's room was free of roaches. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.Findings included: Record review of Resident #35's admission MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a BIMS score of 04, indicating severe cognitive impairment. Resident #35's diagnosis included heart failure, high blood pressure and kidney disease. His Functional abilities assessment revealed he required setup or clean-up assistance with eating, oral and personal hygiene. Nutritional approaches included mechanically altered diet. Record review of Resident #35's care plan, undated, Resident #35 has impaired cognitive function or impaired thought processes related to difficulty making decisions. Goal: Resident will have no unmet needs. Interventions included resident needs assistance with all decision making. Record review of Pest Control Contract dated 03/13/26 revealed, We (Pest Control) agree to furnish Integrated Pest Management service for the period of 1 year; said contract to be renewed at the end of one year with agreement by both parties. Monthly General Pest Control the following pests: roaches, spiders, ants (excluding the crazy ant and carpenter ant), box elder, silverfish, wasp, pillbug, earwigs and rodents. Record review of pest control book revealed visits on:07/01/26 target pest: snakes;06/17/26 target pest: monthly service;06/02/26 target pest: German roaches and Bed Bugs;05/29/26 target pest: bed bugs;05/19/26 target pest: ants, roaches, spiders;04/20/26 target pest: German Roaches;11/19/25 target pest: roach spider ants;10/25/25 target pest: roach prevention; Interview and observation on 07/13/2026 11:20 AM with Residents #35 revealed Resident #35 lying in bed and stated he had concerns with roaches in his room as he pointed to the nightstand. Roaches were observed on the nightstand, roaches were crawling up, down and around Resident #35's personal belongings to include cups, personal hygiene products and food. Further observations revealed at least 10 roaches on the floor coming in and out from underneath the bottom of the nightstand and along the baseboards and behind Resident #35's nightstand. Interview on 07/13/26 at 2:35pm with Family Member B revealed Resident #35 had lots of roaches in his room everywhere. According to Family Member B the facility had treated Resident #35's room at least 3 times, however they had not gotten rid of the issue. Family Member B stated during visits you could notice roaches over food covered in boxes at his nightstand and bedside table, The roaches will beat you to the food they are out and about, and you can see them, especially at night. Interview on 07/14/26 at 3:43 PM CNA K reported he had never observed Resident #35 with roaches in his room and had not had any complaints from Resident #35 about roaches or pests. According to CNA K he has seen pest control in the facility and housekeeping making daily rounds to Resident #35's room. Interview and observations on 07/14/2026 at 3:45 PM revealed Resident #35 in bed, pointing at his nightstand and saying he had a lot of roaches and asked surveyor to open the drawer. Observation further revealed resident's nightstand with at least 30 roaches crawling all over the nightstand. Interview and observation on 07/14/2026 at 4:01 PM with the DON revealed at least 15 roaches at the resident's nightstand, the DON stated she heard roaches were on the hall however had never seen them. The DON stated she would alert the Maintenance Director and immediately left Resident #35's room. Interview and observation on 07/14/26 at 4:10 PM the DON stated she and Maintenance Director entered Resident #35's room, opened the drawer to find open food and roaches all over the place. According to the DON, the Maintenance Director stated he was going to call pest control. The DON stated she had been in the facility for 6 weeks and had only seen pest control once, she was not sure if there had been an issue with the contract or what, however not providing pest control placed residents at risk of decline in care, dignity, quality of life. The DON stated it was the responsibility of all staff to report any pests they see to the Maintenance Director and the Maintenance Director was responsible to maintain the building and eliminate pests as much as possible. Interview on 07/14/2026 at 4:17 PM the Maintenance Director stated he was not aware residents had issues with roaches, this was the first of him hearing about it. The Maintenance Director reported he called pest control and they will be here tomorrow (07/15/26) at 1:00 PM. According to the Maintenance Director when he opened the drawer, he only saw 1 roach and that was enough for him, he further stated there was a current pest control contract and pest control was last present in the facility about 3 weeks ago. The Maintenance Director stated it was the responsibility of staff to notify him if they see pests in the facility so he can ensure he notified pest control, not doing so could cause infestations. Review of the facility's guidance Pest Control, reflected 05/2008, reflected the following: Our facility shall maintain an effective pest control program.1.This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observations, record reviews, and interviews, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for 5 (Resident #5, #7, #25, #39, and #58) of 20 Residents reviewed for safe, comfortable, homelike environment. The facility failed to ensure call light cords were within reach of Resident #5, #7, #25, #39, and #58. This failure could place residents at risk of not being able to summon help if needed which could result in diminished quality of life and potential injuries.Findings included: 1. Record review of Resident #5' quarterly MDS assessment, dated 06/08/26 reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, heart disease, and diabetes. Her BIMS score was 12, indicating she was cognitively intact. Her Functional Abilities assessment reflected she was dependent on staff for her ADLs. Record review of Resident #5's care plan, dated 06/11/26, revealed she had asthma and required oxygen, she required feeding via her gastric tube, and she had an ADL self-care deficit. Observation on 07/13/26 at 10:25 AM revealed Resident #5's adaptive call light was located out of reach on her nightstand. Observation on 07/15/26 at 10:00 AM revealed CNA-A and CNA-B entered Resident #5's room to check on her and exited the room without placing the resident's call light within reach. Interview on 07/15/26 at 10:03 AM CNA-A and CNA-B both exited Resident #5's room and stated they did not notice where Resident #5's call light was placed. CNA-A stated it important to have her call light where she could reach it in case she needed to call for help. 2. Record review of Resident #7's quarterly MDS assessment, dated 07/07/26, reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke, muscle wasting, and cognitive communication deficit. MDS revealed resident had a BIMS score of 1, indicating severe cognition. Functional ability assessment indicated he was dependent on staff with his activity of daily living skills and transferring in and out of bed. Observation on 07/15/26 at 10:12 AM revealed Resident #7 was in bed, with his call light located out of reach in his nightstand. In an interview on 07/15/26 at 10:12 AM Resident #7 stated he did not know where his call light was, and he often used it to notify staff of his wants and needs. 3. Record review of Resident #25's annual MDS assessment, dated 05/10/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included prostate cancer, weakness, diabetes, and dementia. His BIMS score was 14 indicating he was cognitively intact. His Functional Assessment indicated he required minimal assistance with his ADLs. Record review of Resident #25's care plan, dated 06/11/26, reflected he had fatigue related to anemia, bowel incontinence, and had some cognitive deficits. Observation on 07/15/26 at 10:15 AM revealed Resident #25 in bed, call light was out of reach; it was tucked under the fitted sheet under his bed. In an interview on 07/15/26 at 10:15 AM Resident #25 stated he did not know where his call light was located. He stated staff always put it where he could not reach it. 4. Record review of Resident #58's quarterly MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke affecting his left side, diabetes, and chronic pain syndrome. His BIMS score was 13, indicating he was cognitively intact. His Functional Ability indicated he was mostly independent with his ADLs. Record review of Resident #58's care plan, dated 07/02/26, reflected he required assistance with dressing the left side of his body, had diabetes, and was incontinent of bowel. Observation on 07/15/26 at 10:18 AM revealed Resident #58 was in bed with his call light located out of reach on the floor under his bed. In an interview on 07/15/26 at 10:18 AM Resident #58 stated staff forget to clip his call light to his bed, and it always fell off where he was unable to reach it. Resident #58 stated he used the call light to notify staff when he needed assistance. 5. Record review of Resident #39's quarterly MDS assessment, dated 05/23/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke, diabetes, and placement of feeding tube. Her BIMS score was not calculated due to her medical condition. Her Functional Abilities assessment indicated she was totally dependent on staff for her ADLs. Record review of Resident #39's care plan, dated 6/11/26 revealed she was dependent on staff for her ADLs, was a high risk for skin breakdown. Observation on 07/15/26 at 10:22 AM revealed Resident #39 was in bed sleeping, her call light was located between the wall and her nightstand. In an Interview on 07/15/26 at 10:30 RN-C stated it was important for the resident's call light to always be within their reach, even when they were up in a chair, so the resident could call for assistance if they needed help. He stated there was a risk of the resident being injured trying to get up unassisted. In an interview on 07/15/26 at 10:41 AM the DON stated call lights always needed to be within the reach of the resident. She stated the cord should be secured to the resident's bedding or clothes with the clip on the cord. She stated the risk to the resident if they could not call for assist could be falling trying to get up. Record review of the facility's undated policy Answering the call light, reflected: 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower, and from the floor.

Based on observations and interviews 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 3 residents (Residents #33, #56, and #65) of 8 residents reviewed for infection control.Medication Aide-E failed to sanitize the reuseable blood pressure cuff between uses on Residents #33, #56, and #65. This failure could place residents at risk from infection from another resident. Findings included:Observation on 07/14/26 at 7:58 AM MA-E checked Resident #33's blood pressure prior to administering her morning medications. Upon returning to his cart after administering her medications, he failed to sanitize the blood pressure cuff prior to moving on to Resident #56.Observation on 07/14/26 at 8:21 AM MA-E did not sanitize his blood pressure cuff prior to checking Resident #56's blood pressure. Upon returning to his cart, MA-E failed to sanitize his blood pressure cuff before moving on to Resident #65. Observation on 07/14/26 at 8:29 AM MA-E did not sanitize his blood pressure cuff prior to checking Resident #65's blood pressure. Upon returning to his cart, MA-E did not sanitize his blood pressure cuff. Interview on 07/14/26 at 8:40 AM MA-E stated he was not aware he did not sanitize the blood pressure cuff between residents. He stated he knew to do that, but just forgot to do so today. He stated it was necessary to sanitize between uses to prevent spreading an infection. In an interview on 07/14/26 at 9:44 AM the DON stated her expectation was for any re-useable medical equipment to be properly sanitized before it was used on another resident. She stated proper sanitization helped prevent spreading any infection from one resident to another. Review of the facility's guidance, reflected: All staff are reminded that any equipment used on a resident MUST be clean and disinfected immediately after each use.This includes, but is not limited to: gait belts, lift slings, blood pressure cuffs.

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 8 residents (Residents #9 and #22) reviewed for baseline care plans. The facility did not develop a baseline care plan for Residents #9 and #22 within 48 hours of admission. This failure could place new residents at risk of not receiving necessary care and services or having important care needs identified.Findings included:Record review of Resident #9's admission MDS Assessment, dated 07/03/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain dysfunction caused by systemic illness or organ failure), malnutrition (poor nutrition), and osteoporosis (bone disease). The MDS reflected that the resident's cognition was moderately impaired with a BIMS score of 08. Her Functional Abilities assessment reflected she was dependent on staff for her ADLs. Review of Resident #9's electronic health record revealed the resident's 48-hour baseline care plan was started on 06/27/26 but was not completed. Record review of Resident #22's admission MDS Assessment, dated 04/23/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included chronic respiratory failure, hypertension (high blood pressure), hemiplegia and hemiparesis (one sided weakness/paralysis) following cerebral infarction (stroke) affecting right dominant side and tracheostomy status (surgical airway opening in the neck). The MDS reflected that the resident's cognition was cognitively intact with a BIMS score of 15. Review of Resident #22's electronic health record revealed the resident's 48-hour baseline care plan was started on 04/18/26 but not completed. Interview on 07/15/26 at 3:12 p.m., RN C stated when a resident admitted to the facility, the nurse on duty was expected to complete all assessments that made up the baseline care plan. He stated the baseline care plan should be completed within 48 hours of admission. RN C reviewed Resident #9 and Resident #22's electronic health record and stated the baseline care plans were not completed. He stated he was not aware the baseline care plans were not completed. RN C stated baseline care plans must be completed within 48 hours of admission to ensure staff were aware of the resident's immediate short-term goals and ongoing goals. Interview on 07/15/26 at 3:53 p.m., the ADON stated baseline care plans were completed by the admission nurse and the interdisciplinary team. She stated the admission nurse completed the admission portion of the baseline care plan, then the interdisciplinary team would review and sign off. She stated she was not aware Resident #9 and Resident #22's baseline care plans were not completed. She stated it might just need a signature. The ADON stated during morning meetings the interdisciplinary team reviewed all new admissions and ensure required assessments were completed timely. Interview on 07/15/26 at 6:16 p.m., the DON stated her expectation was for baseline care plans to be completed within 48 hours by the admission nurse. She stated it was the responsibility of the ADON and herself to ensure they were completed. She stated she was not aware baseline care plans were not being completed. She stated if baseline care plans were not completed timely the potential risk would be nursing staff may not be aware of the resident expected plan of care. Record review of facility Care Plans - Baseline revised 03/2022, reflected the following: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 (Resident #10 and #20) of 8 residents for care plan revisions, in that:The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #10's psychoactive medication use.The failure could place residents at risk of receiving inappropriate care.Findings included:Record review of Resident #10's quarterly MDS Assessment, dated 06/05/26, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #10 had diagnoses which included major depressive disorder, recurrent severe without psychotic features, psychotic disorder (mental disorders that cause abnormal thinking and perceptions), and Non-Alzheimer's Dementia (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). The MDS reflected that the resident's cognition was moderately impaired with a BIMS score of 09. The MDS also revealed the resident received antipsychotic, antianxiety and antidepressant medications 7 days a week.Review of Resident #10's Care Plan revised 04/08/26 revealed there was no care plan addressing Resident #10's psychoactive medication use.Record review of Resident #10's July active physician orders revealed the following: - Quetiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth three times a day for Major depressive disorder, recurrent, severe, with psychosis. Start date 05/01/26. - trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth one time a day for Insomnia. Start date: 05/01/26. - Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Major depressive disorder, recurrent, severe, with psychosis. Start date: 05/02/26.Record review of Resident #10's July [DATE] revealed the resident was receiving the following medications as scheduled: - Quetiapine Fumarate Oral Tablet 100 mg by mouth three times a day; - trazodone HCl Oral Tablet 50 mg by mouth once a day; and- Sertraline HCl Oral Tablet 50 mg by mouth once a dayInterview on 07/15/26 at 5:32 p.m. the MDS Coordinator stated she was responsible for completing and updating comprehensive care plans. She stated residents who were receiving antipsychotic medication and were having behaviors should be care planned. The MDS Coordinator reviewed Resident #10's physician's orders and stated the resident was receiving antidepressant and antipsychotic medications. She reviewed Resident #10's care plan and stated the resident was not care planned for the use of the medications. She stated it was a mistake and it should have been care planned. She stated the potential risk of not care planning for antipsychotic medication would be staff may not know what to monitor or which interventions were in place. Interview on 07/15/26 at 6:08 p.m., the DON stated it was the responsibility of the MDS Coordinator to complete and update residents' care plans. She stated residents who were receiving antipsychotic medication should be care planned. She stated the potential risk of not care planning for antipsychotic medications would be plan of care not being followed for the use of the medication. Record review of Care Plans - Baseline policy did not address comprehensive care plan. Policy was requested but not provided prior to exit. Record review of facility Informed Consent for Psychotropic Drugs policy undated, reflected the following: For residents on psychotropics: Ensure IDT involvement in care planning, including review of indications, nonpharmacological alternatives, GDR, and monitoring for side effects.IDT Process: Review psychotropic use in care planning conferences; include assessment of condition, interventions, impacts, alternatives. Re-evaluate at least quarterly or upon significant change[BR3.

Based on observations and interviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 Resident (Residents #5, #9) of 9 residents reviewed for pressure ulcer treatment. 1. The facility failed to ensure Residents #5 and #9 had dressings covering their wounds.2. The facility failed to ensure Resident #9 received wound care as ordered by the physician on 07/14/26. These failures could place residents at risk of developing wound infections. Findings included: 1. Record review of Resident #5's quarterly MDS assessment, dated 06/08/26 reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, heart disease, and diabetes. Her BIMS score was 12, indicating she was cognitively intact. Her Functional Abilities assessment reflected she was dependent on staff for her ADLs. Record review of Resident #5's care plan, dated 06/11/26, revealed she had asthma and required oxygen, she required feedings via her gastric tube (a medical device inserted directly through the abdominal wall into the stomach), and she had an ADL self-care deficit. Record review of Resident #5's physician's orders revealed an order dated 07/10/26 Cleanse stage 1 pressure injury (earliest sign of skin damage) on coccyx (tailbone) with WC/NS. Apply zinc oxide every shift and place mepilex dressing every shift for Wound on coccyx AND as needed for PRN Wound Care Observation on 07/15/26 at 2:18 p.m., of wound care, provided by the Wound Care Nurse, CNA-A, and CNA-B, revealed when Resident #5's brief was opened she had been incontinent of stool, and the dressing to her coccyx was not in place. Incontinence care was provided and wound care was completed. In an interview on 07/15/26 at 2:33 p.m., CNA-B stated she did not see a dressing to Resident #5' coccyx since she checked the resident around 8:00 AM and again around 12:00 PM. She stated she did not notify the resident's nurse. In an interview on 07/15/26 at 2:34 p.m., the Wound Care Nurse stated leaving the wound open and exposed to stool could cause the resident to develop an infection in the wound. She stated the bedside nurse could change or replace the dressing if it became saturated or fell off, based on the physician's order. In an interview on 07/15/26 at 2:40 p.m., RN-C stated he was not made aware of Resident #5's dressing not being in place. He stated if a dressing came off, he could replace it, or if it was their scheduled wound care day he could check with the wound nurse for guidance. He stated a wound left exposed could cause an infection. 2. Record review of Resident # 9's admission MDS Assessment, dated 07/03/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain dysfunction caused by systemic illness or organ failure), malnutrition (poor nutrition), and osteoporosis (bone disease). The MDS reflected that the resident's cognition was moderately impaired with a BIMS score of 08. Her Functional Abilities assessment reflected she was dependent on staff for her ADLs. The MDS reflected Resident #9 admitted to the facility with an unstageable pressure ulcer (a wound where the true depth and extent of the damage cannot be determined). Record review of Resident #9' care plan, dated 07/13/26, reflected Focus: [Resident #9] was admitted with a Unstageable pressure ulcer to right buttock. Goal: The resident will have no complications from Pressure Injury through the review date. Interventions: Implement wound care protocol. Review of Resident #9's physician's orders revealed an order dated 07/02/26 Cleanse unstageable pressure injury on right buttock daily and PRN for excessive drainage or dislodgement. Clean with NS/WC, apply Santyl activate with moist gauze and placed bordered foam dressing one time a day AND as needed for leakage or dislodgement. Record review of Resident #9's July 2026 TAR/WAR reflected there was no documentation showing Resident #9 received wound care on 07/14/26. Interview on 07/15/26 at 2:40 p.m., Resident #9 was observed in bed. The resident stated she was doing well. Resident #9 stated she was admitted to the facility with a wound on her bottom. Resident #9 stated she received wound care but could not recall how often. Observation on 07/15/26 at 2:58 p.m., of wound care for Resident #9, performed by the Wound Care Nurse, CNA-A, and CNA-B, revealed her dressing to her coccyx was not in place when her brief was removed and the wound was covered with stool. Incontinence care was provided and wound care proceeded. In an interview on 07/15/26 at 3:03 p.m., RN C stated he was the nurse assigned to Resident #9. He stated he was not made aware Resident #9 did not have a dressing in place. He stated it was expected for the CNAs to notify him or the Wound Care Nurse if no dressing was in place so that they could put one on. He stated Resident #9 received wound care daily. RN C reviewed Resident #9's TAR/WAR and stated based on documentation it did not appear resident received wound care yesterday (07/14/26). He stated Monday through Friday it was the responsibility of the Wound Care Nurse to provide wound care and on the weekends it would be the assigned nurse. He stated if the Wound Care Nurse was unable to provide wound care, she would notify the nurse to complete the wound care. RN C stated the potential risk of a wound not having a dressing or not providing wound care could lead to an infection. In an interview on 07/15/26 at 3:30 p.m., CNA D stated she had not noticed a dressing being in place since the beginning of her shift at 6 AM. She stated she did not notify the nurse, she knew it was her day for wound care and thought it could wait. In an interview on 07/15/26 at 4:11 p.m., the ADON stated her expectations were for wounds to be covered unless physician's order indicated otherwise. If the dressing came off when completing care, the aides were to notify the nurse or inquire if the wound needed to be covered. She stated the risk of not having a dressing on could affect the healing process. In an interview on 07/15/26 at 4:02 p.m., the DON stated her expectation for the CNAs, if they noticed a dressing missing or in need of change, was for them to notify the nurse. She expected the nurse to change the dressing immediately; it was not acceptable to delay dressing replacement just because it was their wound care day. Observation on 07/15/26 at 4:55 p.m. of Resident #9's pressure ulcer site conducted by the Wound Care Nurse revealed pressure ulcer had no signs of infection. In an interview on 07/15/26 at 5:00 p.m., the Wound Care Nurse stated wound care was performed on the weekends, or when she was not available, by the bedside nurse. She stated the nurse would know the dressing was due to be changed because it would populate on their treatment record, plus there was a physician's order they could read to guide them on how to change the dressing. The Wound Care Nurse reviewed Resident #9's WAR and stated she failed to provide wound care yesterday (07/14/26) and failed to notify the nurse. She stated she did not complete wound care because she was occupied and did not have time to complete it. She stated not providing wound care, leaving a wound open and exposed to stool could easily cause infections and/or sepsis (life-threatening reaction to an infection). Follow – up interview on 07/15/26 at 6:06 p.m., the DON stated her expectation was for wound care to be completed daily by the Wound Care Nurse. Physician's orders must be followed. She stated she was not aware Resident #9's wound care was not completed on 07/14/26. She stated if the wound care was not completed by the Wound Care Nurse, she must notify the nurse. She stated the potential risk of not providing wound care could lead to an infection. Record review of facility policy Skin Management, dated 06/2022 reflected the following: Residents receive care to aid in the prevention or worsening of wound and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new pressure injuries from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes.

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 5 residents (Resident #10) reviewed for adequate monitoring of unnecessary medication.The facility did not monitor Resident #10 for side-effects related to the use of the anti-depressant medications Sertraline, Trazodone and the anti-psychotic medication Quetiapine Fumarate.This failure could place the residents at risk for adverse consequences of medication. Findings includedRecord review of Resident #10's quarterly MDS Assessment, dated 06/05/26, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #10 had diagnoses which included major depressive disorder, recurrent severe without psychotic features, psychotic disorder (mental disorders that cause abnormal thinking and perceptions), and Non-Alzheimer's Dementia (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). The MDS reflected that the resident's cognition was moderately impaired with a BIMS score of 09. The MDS also revealed the resident received antipsychotic, antianxiety and antidepressant medications 7 days a week.Review of Resident #10's Care Plan revised 04/08/26 revealed Focus: [Resident #10] has a behaviors including paranoia, delusions, medications hyper fixation, r/t to recurrent severe, Majoy Depressive Disorder w/psychotic features. Goal: The resident will have fewer episodes of hyper-fixation on medications and health conditions by review date. Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness.[sic] There was no care plan addressing Resident #10's psychoactive medication use.Record review of Resident #10's July 2026 Active physician orders revealed orders for the following medications: -QUEtiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth three times a day for Major depressive disorder, recurrent, severe, with psychosis. Start date 5/1/2026. -traZODone HCl[VT1.1] Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth one time a day for Insomnia. Start date 5/1/26. -Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Major depressive disorder, recurrent, severe, with psychosis. Start date 05/02/26. The orders did not include any orders to monitor for side-effects related to the use of the Quetiapine, Trazodone, and Sertraline. Record review of Resident #10's Consultant Pharmacist Medication Regimen Review dated 06/30/26, reflected Please monitor specific behavior seen and any side effects with use of psychoactive medications given. Observation on 07/13/26 at 10:28 a.m. Resident #10 was in her room sleeping, there was no response to verbal communication. No distressed or discomfort noted.Interview on 07/15/26 at 4:00 p.m. ADON stated residents receiving antipsychotic medications should have monitoring orders in place as part of their ongoing medication review. ADON reviewed Resident #10's physician orders and stated there were no monitoring orders in place. She stated the DON was responsible for reviewing pharmacy recommendations for the month of June 2026. She stated for residents receiving antipsychotic medication the expectation was for monitoring orders to be obtained. She stated it was the nurses' responsibility to obtain the orders. She stated potential risks of not monitoring antipsychotic medication would be not knowing the therapeutic effectiveness of the medication or adverse effects. Interview on 07/15/26 at 6:08 p.m. the DON stated certain medications should be monitored for side effects. The DON stated she was not aware Resident #10 had no orders for monitoring side effects for the use of psychotropic medication. She stated for residents receiving psychotropic medication the expectation was for monitoring orders to be obtained and it was the responsibility of the nurses. She stated it was the responsibility of ADON and herself to ensure orders were put in place. The DON stated the potential risk if staff were not monitoring the side effects of medications could lead unwanted side effects. Record review of facility Orders, Receiving and Transcribing police revised 02/24, was provided; however, it does not address monitor for behavioral or side effects.Record review of the facility's current, undated Informed Consent for Psychotropic Drugs policy reflected the following: For residents on psychotropics: Ensure IDT involvement in care planning, including review of indications, nonpharmacological alternatives, GDR, and monitoring for side effects.

Based on interviews and record reviews, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #20) of 3 residents reviewed for discharge planning.1. The facility failed to notify Resident #20 of discharge, reasons for the move, and right to appeal in writing, in a language and manner he understands, and at least 30 days before Resident #20 was discharged from the facility on 07/13/26. 2. The facility failed to send a copy of the Resident #20's notice of discharge to the facility's Ombudsman.This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. Findings includedRecord review of Resident #20's discharge MDS Assessment, dated 07/13/26, revealed a [AGE] year-old male who admitted to the facility on [DATE] and discharge 07/13/26. Resident #20 had diagnoses which included spinal stenosis, lumbar region with neurogenic claudication (narrowing of the lower spinal canal, compressing nerve roots), and Type 2 diabetes mellitus without complication (sustained high blood sugar levels). Resident #20's cognition was moderately impaired with a BIMS score of 12. The MDS assessment section A indicated resident's discharge return not anticipated, it was a planned discharge to Home/Community. Record review of Resident #20's care plan, revised 06/14/26, reflected there were no notes related to Resident #20's discharge goals and plans.Record review of Resident #20's Care Plan Conference dated 6/3/2026 Type of Conference: Other; DC Planning; IDT follow- up plan: assist resident with transition to community as per his preference. Record review of Resident #20's Care Plan Conference dated 6/26/2026 Type of Conference: Quarterly; Specify social services care plan change(s): Working on discharge plan; Additional comments: [Resident #20] wants facility to finish discharge plan. Record review of Resident #20's progress notes from 07/10/26 through 07/13/26 reflected: -A note by the Operations Director on 07/10/26 at 15:10 [3:10 PM] This writer has been working on [Resident #20] discharge planning with him. He has been added to the waitlist for two low-income apartment options in [name] City. [Resident #20] has agreed to transition to the community to a long stay hotel that the facility will cover the cost of the first two weeks as well as provide food for the week and toiletry items. [Resident #20] had no disagreement to this, the DON and Medical Records staff were present at the time as well. The monthly cost of the hotel was reviewed with [Resident #20] and is within his budget. Facility to also is sending a referral for Home health to an agency that will accept VA benefits. This writer did talk to the Ombudsman previously in the week regarding the discharge. The physician agrees to the discharge. Per physician, this writer did notify the emergency contact #1 so they are aware of the discharge. The information for the two apartments that [Resident #20] is on the waitlist for will be provided to him so he can follow up as needed. Discharge is planned for Monday, 7/13.-A note by the Operations Director on 07/10/26 at 15:58 [3:58 PM] With the BOM present, this writer confirmed that [Resident #1] is [sic] accepting of his discharge plan. Services were reviewed to ensure that he understood a home health referral was being sent for a provider that accepts his VA benefits, the facility would pay for the first two weeks and that the facility would provide groceries and personal items for his transition. [Resident #20] was very appreciative at this time. The Activity Director will provide [Resident #20] with a list of meals for wheels services in [city].-A note by the BOM on 07/10/26 at 16:05 [4:05] This writer, BOM, and administrator talked to [Resident #20] regarding his discharge plan. He was more than agreeable and thankful for all our help. BOM assisted in setting up home health for the Monday discharge.-A note by the BOM on 07/13/26 at 9:41 The writer, BOM, and receptionist, went to speak with [Resident #20] regarding his discharge. He expressed concerns about financials. We assured him the motel would be covered and provided documentation with that. He was still disagreeing. We then informed him that his needs no longer fit those of a skilled nursing facility. He said he understood but was still acting hesitant. BOM then informed administrator of the conversation.-A note by the LVN on 07/13/26 at 15:05 [3:05] Resident discharged from the facility on 07/13/2026 at 1500 [3:00]. Discharge completed per physician orders. Resident departed the facility with all personal belongings, prescribed medications, and discharge instructions. Appropriate discharge paperwork was completed and provided. Resident left the facility in stable condition with no acute distress noted at the time of discharge.Record review of Resident #20's Discharge Summary/Post discharge Plan of Care dated 07/13/26 reflected: Resident was admitted to the facility on [DATE] with a primary diagnosis of spinal stenosis, lumbar region with neurogenic claudication. During his stay, the resident received skilled nursing services, prescribed medications, and physical and occupational therapy to address his diagnosis and improve his functional abilities.The resident participated in therapy as tolerated, with care focused on improving strength, mobility, balance, endurance, and activities of daily living. Medications were administered as ordered, and the resident was routinely monitored for pain control, safety, and response to treatment.During his stay, the resident also exhibited behaviors that required staff intervention, including smoking in front of the facility despite facility policies. There were also concerns regarding suspected illegal drug use, which were addressed according to facility policy, with the appropriate notifications and interventions implemented.Skilled nursing assessments were completed throughout the stay, and the resident's plan of care was updated as needed. The resident has completed his skilled stay and will continue with the recommended plan of care and follow-up services as appropriate.discharge date /time: 07/13/26 at 13:00 [1:00] Transportation: Private Vehicle Discharge to location: [blank] Interview on 07/13/26 at 12:02 p.m., Resident #20 stated he was doing well. Resident #20 stated he was being discharged from the facility today (07/13/26). He stated he was told he was being transferred because he was not following facility smoking policy. Resident #20 stated he was never provided with a discharge notice, he was only told he was going to a hotel that the facility would be paying for, for 2 weeks. He did not know where the hotel was located or how much it was. Resident #20 stated he did not care if he stayed or left, his only concern was financial. He stated he did not want to pay for a hotel if it was over his budget. Resident #20 stated he was told he was going to be discharged on Friday 07/10/26, which gave him no time to prepare. Interview on 07/14/26 at 9:02 a.m. Resident #20's Family Member A stated Resident #20 was not provided with a 30-day discharge notice or any notice of discharge. Family Member A stated on Friday 07/10/26 a phone call was received notifying them of the discharge. Family Member A stated Resident #20 was being discharged because he was not following the facility smoking policy and use of illegal substance in which the resident denied. Family Member A stated Resident #20 stated the facility was working on a discharge but no definitive decision was made. Interview on 07/14/26 at 9:45 a.m. the Ombudsman stated on 07/07/26 the Operational Manager told her, giving you a head up, we going to discharge [Resident #20]. She stated she had not receive any notification of the resident's discharge. She stated on 07/10/26 she was contacted by Resident #20 and informed her he was being discharged on 07/13/26. She stated she was informed by the facility that the resident was being discharged for not following smoking policy. She stated she assumed Resident #20 was going to get a 30-day discharge notice because of the reason of discharge. She stated she was not informed Resident #20 was being discharged because he did not have medical necessity to be able to stay at the facility any longer. She stated if there was a facility initiated discharge the facility was required to provide a 30-day written notice to the resident, their family/representative, and the ombudsman. Per the conversation she had with Resident #20 on 07/10/26 the resident agreed to go but then on Monday 07/13/26 he did not want to leave. Interview on 07/14/26 at 2:43 p.m., LVN J stated she completed Resident #20's discharge paperwork. She stated she completed the discharge summary and resident was discharged to a hotel. LVN J stated she did not put the location of the hotel on the discharge summary because she did not have an address. LVN J stated she was not sure if Resident #20 received a 30-day discharge notice. LVN J stated Resident #20 did not require any assistance, he was able to do everything on his own. Interview on 07/15/26 at 12:52 p.m. the Operations Director stated on 06/03/26 a care conference was held with Resident #20 and the goal was for Resident #20 to return to the community. She stated Resident #20 agreed to the discharge because his health had improved and he no longer needed services. The Operations Director stated Resident #20 would also not follow facility smoking policy. She stated a notice was provided to Resident #20. Follow-up interview on 07/15/26 at 6:10 p.m. the Operations Director stated no 30-day discharge notice was provided to Resident #20. She stated a discharge notice was provided today (07/15/26) but the resident refused to sign. She stated no discharge notice was provided prior to today (07/15/26) because it was a planned discharged and the resident agreed to it. She stated the Ombudsman was verbally notified but no official notice was provided. Potential risk of not providing the required 30-day discharge notice would be the resident and/or their family may not be aware of the planned discharge, the reason for the discharge, or the destination following the discharge. Interview on 07/15/26 at 6:46 p.m., the Administrator stated Resident #20 did not receive any services at the facility and it was a planned discharged . He stated Resident #20 did not receive a 30-day discharge notice because they did not know they needed to provide one. The Administrator stated he moved from another state and was unaware of the regulation. He stated after reviewing the Texas Administrative Code it was indicated that a notice should have been provided to Resident #20 and the Ombudsman. The Administrator stated there was no potential risk to the resident if a 30-day discharge notice was not provided. He stated it was a clinical error. Record review of facility Resident admission Agreement undated, reflected the following: The Facility shall provide written notification to the Resident and, if known to the Facility, the Resident Representative (or, if none, to a family member or legal representative of the Resident) in writing, with a copy sent to a representative of the Office of the State Long-Term Care Ombudsman, at least thirty (30) days in advance of transfer or discharge, or, if necessary, as soon as practicable as permitted under applicable law.Leave the Nursing Home: Except in emergencies, nursing homes must give a 30-day written notice of their plan and reason to discharge or transfer you.The nursing home has to safely and orderly transfer or discharge you and give you proper notice of bed-hold and/or readmission requirements.Record review of facility Transfer or Discharge Documentation revised 12/2016, reflected the following: 4. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: . 2. That an appropriate notice was provided to the resident and/or legal representative.

Based on interviews and record reviews the facility failed to ensure residents were screened for mental illness and coordinate with the State mental health authority the need for services for 1 of 4 residents (Resident #1) reviewed for PASARR screening.The facility failed to ensure Resident #1 was screened for services by the mental health authority once he received a diagnosis of Schizophrenia on 01/30/26.[BR31.1]This failure could result in residents with mental illness not receiving services to which they are entitled. Findings included:Record review of Resident #1's admission MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a BIMS score left blank, indicating he could not successfully complete the interview with disorganized thinking. Resident #1's diagnosis included Anxiety Disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues affecting daily functioning and quality of life), Depression (a common and serious mood disorder by persistent feelings of sadness, loss of interest, and a range of emotional and physical problems), and Schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking. Resident #1 showed signs of little interest or pleasure in doing things, feeling, or appearing down, depressed, or hopeless and being short-tempered, easily annoyed nearly every day. His Functional abilities assessment revealed he had impairment on one side, supervision with eating, partial moderate assistance with oral hygiene, and was dependent on staff for toileting, shower/bathing self, lower body dressing and putting on or taking off footwear. Resident #1 required substantial assistance with upper body dressing and personal hygiene. Record review of Resident #1's care plan, undated, reflected he impaired cognitive function/dementia or impaired thought processes effecting communication related to long term alcohol abuse. Resident #1 had a history of refusing care related to schizophrenia. Goals: Resident #1 will maintain current level of cognitive functioning. Interventions included Administer medication as ordered. Monitor/document for side effects and effectiveness. Ask yes or no questions in order to determine the resident's needs. Communication: Use the resident preferred name. Identify yourself at each interaction. Face the residents when speaking and make eye contact. Reduce any distractions- turn off TV, radio, closed door. The residents understand consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty RN expressing self, difficulty understanding others, level of consciousness, mental status.Resident #1 uses antidepressant medication related to Depression. Goal: Resident #1 will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included: Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs being given. Monitor /document /report as needed adverse reactions to Antidepressant therapy; change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes. Psychotropic review per interdisciplinary team at least quarterly and as needed. Resident #1 has mood impairment related to diagnosis of Major Depression Disorder. Goal: Resident will have improved mood state. Interventions included Administer medication as ordered. Monitor/document for side effects and effectiveness. Assist the resident in developing/providing the resident with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. Monitor/document/report as needed any risk for harm to self; suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving way possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Monitor/record/report to physician as needed acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. Monitor/record/report to physician as needed risk for harming others; increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Record review of Resident #1's PASRR Level 1 screening, dated 10/22/24, reflected he did not have a primary diagnosis of dementia, and there was no evidence of mental illness. Record review of Resident #1's clinical chart revealed no PASRR 1 Level 1 screening or Mental Illness/Dementia Resident Review (Form 1012), had been completed after new diagnosis of Schizophrenia on 01/30/26 by the psychiatrist.Interview on 07/13/2026 11:07 AM, Resident #1 denied any mental illness and stated he was able to voice his needs and concerns. Interview on 07/13/26 at 1:26 PM, MDS Coordinator A stated Resident #1 had a negative PASRR Level 1 Screening on 10/22/24 due to him not having evidence of mental illness. Interview on 07/14/26 at 11:13 AM, RN I stated Resident #1 had behavior issues when he was triggered. RN I stated she was aware of the Schizophrenia diagnosis however Resident #1 did not require a lot of interventions because he stayed in his room most of the time and could voice his needs. She stated the CNAs provided him with incontinent care, helped him dress in the mornings, and assisted him in his wheelchair if needed. RN I stated the MDS Coordinator was responsible for assessing residents for PASRR screenings, not doing so placed residents at risk of missing services and care that could add to quality of life.Interview on 07/15/2026 5:43 PM Regional MDS Coordinator B stated she was not aware Resident #1 had a new diagnosis of Schizophrenia, therefore had not been screened or referred to the local mental health authority after the new diagnosis. Regional MDS Coordinator B stated Resident #1's diagnosis came from the psychiatrist; therefore, a new screening would be required. Regional MDS Coordinator B stated she would complete the Mental Illness/Dementia Resident Review (Form 1012) for the doctor to sign off indicating that Resident #1 would remain negative because Schizophrenia would have needed to be diagnosed around the age of 21. She stated Resident #1 not being assessed after the new diagnosis placed him at risk not receiving services and care he might qualify for. She stated she and the other MDS Coordinator was responsible for performing the MDS assessments and referring residents to the local authority. She stated she did not know why Resident #1 had not been referred to for PASRR services in January 2026 when he got the new diagnosis. Record review of the facility's current, undated PASRR Completion Policy, reflected the following: The Center will a make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. 1. Center Administrator will designate either the Admissions Director or Social Worker to make sure that the PASSRR and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which might constitute an SMI or ID, the PASRR must be completed prior to admission. If the resident is deemed hospital exempted that must be clearly documented in the transfer documents prior to admission from the acute care facility.2.Administrator will also designate a backup in case the designated person is not available.3.Administrator is accountable for monitoring the process of completing the necessary paperwork for the admission.4.Business Office Manager (BOM) must have copies of the LOC and/or PASSRR in the Business Office resident file.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters reviewed for garbage disposal. -The facility failed to ensure one dumpster door and surrounding gate were secured. -The facility failed to ensure one dumpster was emptied and not overflowing. -The facility failed to clean the areas around both dumpsters. These failures could place residents at risk of infection, and potential exposure to vermin and pests from improperly disposed of garbage. Findings include: Observation on 06/30/2026 at 3:32 pm, revealed an open white and metal gate that exposed a green garbage dumpster with the door open. There were two large blue plastic barrels that were uncovered and had clear plastic bags inside that appeared to contain linens. There was a variety of trash on the ground around and directly in front of the dumpster and a broken white PVC shower chair. Just outside of the open white and metal gate there was a dilapidated red shed that did not appear to have a door and was open and exposed from the front. There was a corner of the roof was missing. The dilapidated shed was filled with what appeared to be water damaged materials and the shed itself appeared to be leaning to the side. Continued observations of an approximately 40-yard-long dumpster that was filled to the brim and observed cardboard boxes in a pile behind and in the grass behind the dumpster. There was a black wheelchair folded up in front of the dumpster along with a 4-foot stacked pile of wooden pallets on the side of the dumpster, and between the dilapidated red shed structure. There were various white plastic bags and debris surrounding the dumpster and a grey and navy-blue mattress on the side of the full dumpster. Interview and observation on 06/30/2026 at 3:40 pm the Administrator said the waste management company had already come to the facility and was scheduled to come later in the week but could not recall the exact day. The Administrator said the Maintenance Director was responsible for ensuring the garbage area was clean and did not know why the green garbage dumpster door was open, why there was trash on the ground in front of it or why the large blue plastic barrels containing clear plastic bags of linens had no tops on them. The Administrator said the clear plastic bags inside of the two blue barrels may be damaged linens instead of soiled linens. The bags were tied and there were flies and other insects flying and buzzing around outside so the bags were not opened. The Administrator said the green garbage dumpster door should be closed and the blue plastic barrels should be covered or emptied. The Administrator said all the rubbish located around the entire area inside the gate, around the dilapidated red shed and on and around the large 40-foot green dumpster should be cleaned up and the entire area should not look like it did. The Administrator said she would have maintenance and staff clean the areas and remove the cardboard boxes on the ground and in the grass surrounding the dumpster. The Administrator said she would provide invoices for when the 40-foot dumpster was last emptied and she called the Maintenance Director outside. Interview and observation on 06/30/2026 at 3:52 pm the Maintenance Director said he had closed the door to the green garbage dumpster and cleaned up the trash around it earlier in the morning. The Maintenance Director said staff must have left the large blue plastic barrels uncovered and said the clear plastic bags of linens were not necessarily dirty linens but damaged linens and should have been placed inside the green garbage dumpster and the barrels cleaned and taken back inside. He said the white and metal gate should have been closed. The Maintenance Director said the facility had been having trouble with Waste Management Company A coming back out to empty the 40-foot dumpster and had been working on getting them to come back out to empty it. The Maintenance Director said he could not elaborate on what the issue was but that he had called the waste management company a few times to set up a pickup date and time for the 40-foot dumpster. He said the leaning, dilapidated red shed was to be dismantled and that most of the trash and boxes in and around the 40-foot dumpster were from 500 hallway because the facility was going to be renovating that hallway soon. He said it was important to keep the trash area clean to prevent vermin and pests. Record review on 06/30/2026 at 4:30 revealed an emailed response sent from the Administrator that read in part. The haul off dumpster [green 40-foot dumpster] was last serviced on 06/01/2026 and [Waste Management Company A] comes after the month to pick it up. Our accounting resource is currently on the phone with them to ensure they are coming this week now that the month is going to be up. Continued record review of the invoice from Waste Management Company A dated 07/01/2026 revealed a total due of $2,168.97 with a previous balance of $1,823.09. Requested a policy and procedure on waste management or trash removal from the Administrator on 06/30/2026 at 4:33 pm and the Administrator provided an email response on 06/30/2026 at 7:04 pm that reflected, We do not have an official policy for waste management, thank you.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a need to alter treatment significantly, that is a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment for 1 of 3 residents (Resident #1) reviewed for notification. 1. The facility failed to notify Resident #1's NP or MD when Resident #1 refused her medication/s, nutritional supplements, and meal/s from her facility admission on [DATE] through 04/17/2026. 2. The facility failed to ensure Resident #1's physician was notified when the resident had a change in condition and had difficulty swallowing. An immediate Jeopardy (IJ) situation was identified on 04/18/2026. While the IJ was removed on 04/22/2026, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for delayed treatment, interventions, and actual harm. Findings Include: Record review of Resident #1's admission record dated 04/17/2026 revealed a-[AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Wernicke's encephalopathy (an acute life-threatening neurological emergency caused by a severe deficiency of thiamine [vitamin B1] which damages the brain), aneurysm ( a rare, localized, blood-filled bulge in the wall of carotid artery [major blood vessel located on either side of the neck, that supplies oxygen rich blood to the brain, neck and face] and can cause stroke like symptoms), dysphagia (difficulty swallowing) and anorexia (loss of appetite or inability to eat). Resident #1 did not have a diagnosis for her PEG tube (a soft flexible tube inserted through the abdomen directly into the stomach, used for long-term nutrition, hydration, and medication when oral intake is not possible). Record review of Resident #1's admission MDS assessment, dated 03/30/2026, revealed her BIMS score was 14 out of 15 indicating her cognition was considered intact. Review of Section I for Active Diagnoses revealed Resident #1 did not have an active diagnosis for her gastrostomy tube. Continued record review of section K Swallowing/Nutrition Status revealed Resident #1 was coded as having a swallowing disorder that included coughing or choking during meals or when swallowing medications and had a weight of 120lbs and a mechanically altered diet (a diet that required a change in texture of food or liquids.) Record review on 04/17/2026 at 12:03 PM of Resident #1's hospital discharge summary revealed the following diet order: Discharge Orders: Regular Diet: Diet Texture: Pureed 4 Pureed for comfort, not sufficient for nutrition. (sic) Has PEG and should remain NPO (nothing by mouth) otherwise. Record review on 04/17/2026 at 12:07 PM of an undated, unsigned handwritten note located in Resident #1's EMR revealed the following: PEG use (sic) [NAME] @10 am. Pureed/thin (sic) liq diet (pleasure). Jevity 1.5 50 cc NG tube (Tube out). Record review on 04/17/2026 at 1:09 PM of Resident #1's physician order recap report revealed the following active order with a start date of 03/27/2026 and no end date: Regular diet Pureed Texture, regular/thin consistency, for pleasure food. And an active order with a start date of 04/02/2026 and no end date: Enteral feed order every shift. Flush enteral tube with 120 ml water q 8 hours to provide 360 ml water and with 30 ml of water before and after medication administration. Record review on 04/17/2026 at 1:15 PM of Resident #1's physician order report revealed Resident #1 had an active order, dated 04/01/2026 with a start date of 04/02/2026 for Ensure Plus three times a day, 237 ml PO (by mouth) TID. The active order was 6 days after Resident #1 was admitted to the facility on [DATE]. Record review on 04/17/2026 at 1:22 PM of Resident #1's Medication Administration record, dated April 1, 2026 through April 30, 2026, revealed Ensure Plus three times a day, 237 ml PO TID at 7 AM, 12 Noon and 6 PM. Continued record review revealed Resident #1 refused all three administration times on 8 days, (04/03/2026, 04/06/2026, 04/07/2026, 04/08/2026, 04/10/2026, 04/14/2026, 04/15/2026 and 04/16/2026). There were 3 days there was no documentation of administration, and the time slots were completely blank (04/04/2026, 04/11/2026 and 04/12/2026) and 2 days staff documented at 6 PM that Resident #1 was nauseated/vomited or asleep (04/09/2026 and 04/13/2026). Observation and interview with Resident #1 on 04/17/2026 at 11:00AM, revealed she was seated in a wheelchair, at a table alone, in the common area located directly adjacent to the dining room with her breakfast tray in front of her with a plate that was uncovered and appeared to have pureed eggs, a pureed dark colored substance and a smaller pureed tan colored substance. There was an uncovered bowl of oatmeal and 2 clear colored drink cups which were full of liquid and covered. The residents' utensils were unwrapped and were clean of any food debris and an unused napkin sat to the right side of the tray. State surveyor introduced herself to Resident #1 who said the tray was her breakfast tray and she needed help eating it, but no one had come to help her eat her breakfast tray. The State Surveyor remained with resident and requested a passerby to get the DON. Observation and interview with Resident #1, with the DON present, on 4/17/26 at 11:03 AM, the DON said she did not know why the resident was seated in front of her uncovered, uneaten breakfast tray and would have to get the nurse. While the DON was at the table with the resident, the state surveyor asked the resident again, if she was hungry and Resident #1 replied, yes. The DON said she was going to get the residents nurse and or CNA. The State Surveyor remained with Resident #1. In a follow up observation and interview with Resident #1 on 4/17/26 at 1:44 PM, she said she had not had much of an appetite over the last month and had a tube placed in her stomach while she was in the hospital. Resident #1 lifted her gown and exposed a gastrostomy tube. Resident #1 said staff pushed water through her tube daily, but she did not receive any medications or feeding formulas through the tube since she was admitted to the facility. Resident #1 said she could swallow and did not have pain when she swallowed, but the food sometimes seemed like it got stuck. Resident #1 said sometimes she did not like the mushy baby food the facility served. Resident #1 said some of the food served resembled dog food and she would eat what she liked and if she did not like the look, smell, or taste of the food she was not going to eat it. Resident #1 said the hospital would give her a milk-like formula through a tube that went from her nose to her stomach (NG Tube) and before she got to the facility, the hospital removed that tube from her nose and put the new tube directly into her stomach. In an interview with RN A on 4/17/26 at 1:52 PM, who said they notified the NP Resident #1 did not have an enteral feeding formula ordered and just flushed with water but could not recall when he notified the NP, that Resident #1 had no orders for enteral feeding. RN A said he thought he documented his notification but could not remember where. RN A said normally any type of notification would be documented in the resident EMR under progress notes. RN A said he did not give Resident #1 the Ensure and the MA's were responsible for giving Resident #1 the Ensure nutritional supplement and her daily medications. RN A said MA C told him Resident #1 was not taking her medication this past Monday or Tuesday and he did not know Resident #1 was not taking her Ensure supplement until 04/17/2026, after the state surveyor arrived at the facility. RN A said that a resident not taking medications and not taking nutritional supplements would be considered a change in condition and should have been reported immediately to the NP or MD but he had not yet reported this to the NP or MD because he just found out about everything and did not know none of the other nurses had not reported it to the NP or MD either. RN A said he thought the NP and MD already knew about Resident #1's gastrostomy tube status, her diet and poor meal intake and the fact that she was not taking her medications because he thought maybe one of the other nurses told them. RN A said he did not think to report Resident #1's refusals to the DON or ADON, because he felt like everyone already knew about the residents' refusals and he had not really been trained on who to report resident changes to. In an interview with the DON on 04/17/2026 at 1:57 PM, the DON stated she expected staff to report any changes in condition to her and the NP/MD immediately. The DON said she had signs posted at the nurse's station regarding when to call her and change of condition was one of the reasons listed to call her. The DON said the staff were expected to call the MD/NP if they noticed signs or symptoms of a change in condition and should call the NP/MD if an order needed to be clarified or was unclear or if an intervention needed to be changed. The DON said due to staffing changes she was unable to complete audits and check new admission orders, order verifications and changes in condition fell through the cracks. The DON said she was multitasking and working various roles within the facility that included being DON, ADON, staffing coordinator, floor charge nurse, and central supply person. The DON said she did not know Resident #1 had no enteral feeding formula order since her admission on [DATE] and she did not know Resident #1 had been refusing her medications, nutritional supplement, or meals. The DON said she would have notified the NP/MD immediately for appropriate orders for Resident #1 if she had been notified of the issues and refusals, but she knew nothing about them. In an interview with MA C on 04/17/2026 at 2:00 PM, who said Resident #1 had not really been taking her medications or the Ensure supplement since the first day of admission, because she could not swallow. MA C said he would crush the medications and try to mix them with puddings, or jellies or applesauce and Resident #1 would either refuse or spit them out. MA C said he and MA D, who worked the 2pm-10pm shift, often compared notes and strategies on how to get Resident #1 to take her medications but neither had significant success. MA C said he notified the charge nurses RN A and LVN B. MA C said it was a verbal report. MA C said there was a space to document Resident #1's refusals in the EMR and was not sure if he ever put a progress note in regarding RN notification of Resident #1's refusals to take her crushed medications or drink her Ensure supplement. Interview with MA D on 04/17/2026 at 2:39 PM, who said Resident #1 did not take her medication and she notified every nurse she worked with RN A and LVN B on every shift and whenever she worked and Resident #1 refused. MA D said Resident #1 refused all of her medications and supplements and would not take anything orally since she was admitted to the facility. MA D said she notified RN A and LVN B using handwritten notes and verbal reports of the refusals. MA D said she could not recall if she ever documented Resident #1's refusals in the EMR, but said there was a place for them to document in the EMR. MA D said she had no way of knowing whether or not RN A or LVN B notified Resident #1's NP or MD and did not know whether or not she could go to the DON, ADON or administrator regarding the issues, because she had been taught to notify the charge nurse for the resident, which was what she said she did. MA D said Resident #1 had only two medications prescribed for her to take on the 2pm -10pm shift and she did not know if Resident #1 had lost weight and did not know if Resident #1was refusing her meals but was not surprised. Telephone interview with Resident #1's RP on 04/17/2026 at 3:00 PM, who said Resident #1 had not been eating after the aneurysm and the hospital suspected she had a stroke. The RP said Resident #1 lost the use of her right side which included her right arm and hand and had difficulty feeding herself. The RP said on at least 2 separate occasions within the last week, they were alarmed and angered that Resident #1 was seated in front of various meal trays that had not been eaten and had no staff to help her eat. The RP said they confronted RN A about the issue the other day and were told by RN A Resident #1 needed to learn how to use her left hand to feed herself so she could go back home. The RP said they told RN A, Resident #1 was right-handed prior to her illness, hospitalization, and surgery and needed help regardless because she was never left-handed. Resident #1's RP said Resident #1 had the G-tube placed while she was hospitalized because she was not eating enough to sustain herself. Resident #1's RP said they had not been notified that Resident #1 was refusing medications and nutritional supplements. During a telephone interview with the NP on 04/17/2026 at 3:06 PM, she stated she spoke with RN A for the first time about an hour ago about Resident #1's refusals. The NP said she came to the facility at least twice per week and the MD came to the facility at least once per week, so there would be no reason for the staff to not report any issues or concerns regarding resident care. The NP said Resident #1's actual enteral feeding formula order would normally come from the hospital discharge records but she was told by facility staff there were none, so she ordered an RD consultation to ensure the residents' caloric needs came from the dietician. The NP said she knew nothing about Resident #1's refusal of medications or her refusals of Ensure and should have been notified immediately when resident began refusing. The NP said she would have provided other orders if she had been informed of Resident #1's refusals. In a telephone interview with the MD/Medical Director on 04/17/2026 at 4:07 PM, who stated they were never notified by the facility staff that Resident #1 was not drinking her nutritional supplement or taking her medications, or that there were no orders for enteral feeding formula for Resident #1. The MD said they would have expected to be notified right away because all of those things would be considered a change in the resident's condition. The MD said the first time she rounded and saw Resident #1 she had a pureed meal tray and she was told by the facility staff the resident was tolerating the pureed diet. The MD said there was no excuse for the lack of communication regarding Resident #1's change in condition and it would have been an easy fix to ensure Resident #1 had her medications, and proper nutritional intake since she had a G-tube. The MD said it was a facility system failure all the way around and there had been some recent changes of ownership on or around 04/01/2026. Record review of the facility's policy procedure titled Guidelines for Notifying Physicians of Clinical Problems revealed in part: These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. The floor nurse, charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management.When contacting the practitioner, especially at night and on weekends (when physicians not familiar with the residents may be on call), the nurse should have the following information available:1. Detailed description of current issue or problem, including a chronological story of symptoms and treatment to date,vital signs, and results of physical assessment.2. Active medical problems (problem list).3. Pertinent information from any recent hospitalizations (hospital discharge summary or admission history and physicalform).4. Current medications (orders).5. Allergies to medications, food, etc. This was determined to be an Immediate Jeopardy (IJ) on 04/18/2026 at 2:56 PM. The Administrator was notified. The Administrator was provided with the IJ template on 04/18/2026 at 2:56 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 04/19/2026 at 11:07 AM:. The plan of removal reflected the following: PLAN OF REMOVAL:F 580 Name of Facility: Date: 04/19/2026According to the IJ Template, the facility failed to ensure that they immediately informed, notified, or consulted with the resident's physician a significant need to alter treatments. Immediate Action: Corrective Action:Resident #1's physician has been notified that there was no current order for the NPO tube feeding. Registered Dietician gave her recommendations regarding the enteral feeding and a correct MD order with appropriate enteral feeding product has been entered. Resident/Responsible party has been notified. The tube feeding has been initiated by the facility. The physician was notified of the medication refusals. Resident #1's medication order has been updated from PO to NPO and to be administered via g-tube. Physician was also notified of the residents' current weight as of 4/18/2026. Identification of Others An audit was completed on 4/17/2026 to identify any other residents with enteral feeding orders. This was completed by the NHA or designee. No other deficient practices were identified.An audit was completed on 4/18/2026 to identify any residents currently residing in the facility who had a change of condition within the last 72-hours without physician notification. Audit was completed by nurse manager team, or designee. MD was notified of any deficiencies. System Changes- The ADON, or designee, had started educating all nursing staff on guidelines for notifying physicians of changes of conditions, including but not limited to any conditions that may affect mental, physical, or psychosocial well-being. This will be completed by 4/19/2026. Physicians will be notified by phone immediately. If the physician cannot be reached the staff should call the on-call provider and document all attempts at communication, included but not limited to time, number of calls and outcomes. Record reviews on 04/19/2026, 04/20/2026, 04/21/2026 and 04/22/2026 revealed nursing staff in-services with guidelines for when, how and to whom to notify physicians of changes in conditions and included examples of resident changes in condition that would be reportable to a physician. The ADON, or designee, has started educating all nursing staff on guidelines for following physician orders. This will be completed by 04/19/2026. Record reviews on 04/19/2026, 04/20/2026, 04/21/2026 and 04/22/2026 revealed nursing staff in-services with guidelines for following physician orders that included admission order reconciliation and clarification as well as verification of physician orders. The ADON, or designee, has started educating all nursing staff on notifications to the DON, or designee, regarding any changes in condition and refusals of care. This will be completed on 04/19/2026. Record reviews on 04/19/2026, 04/20/2026, 04/21/2026 and 04/22/2026 revealed nursing staff in-services with guidelines for notifying the DON, and ADON of any changes in residents' conditions or refusals or care and included the chain of command process for notification and contact information. All nursing staff who cannot complete training by 04/19/2026 will not be placed on the schedule until training is completed. Nursing staff were educated to notify Registered Dietician with enteral feeding orders by 04/19/2026 by the ADON, or designee. Registered Dietician educated on completing timely comprehensive nutritional assessment on all residents by the facility RN consultant. The Registered Dietician is contracted through Company A. The facility currently has a consultant dietician. This was completed on 04/19/2026. Record reviews on 04/19/2026, 04/20/2026, 04/21/2026 and 04/22/2026 revealed nursing staff in-services with guidelines for notifying the RD with enteral feeding orders. Interdisciplinary team (IDT) was trained by facility RN consultants on daily clinical management tool which review the clinical systems, 24-hour reports, and the daily clinical review with the IDT. Where all physician orders are reviewed, including new admission orders. Orders are reviewed to ensure that they are written correctly, implemented, and residents are receiving physician orders and that the care plan has been updated. Record review of facility audits on 04/20/2026, 04/21/2026 and 04/22/2026 of the facility clinical management tool that included daily reviews of 24-hour reports and clinical reviews conducted by the IDT. Monitoring The facility RN consultant, or designee will complete training for guidelines for notifying physicians of changes of conditions, including but not limited to any conditions that may affect mental, physical, or psychosocial well-being. This will be completed by 04/19/2026. The MD was notified of the IJ by NHA and DON on 04/18/2026.Administrator, or designee, will conduct chart audits to ensure that physician orders are obtained, implemented, and followed through timely, and that the physician, responsible party, resident are notified of refusals and changes of condition. These audits will occur daily (five times per week). Results will be reported to the monthly QAPI. The ADON, or designee, has started educating all nursing staff on guidelines for notifying physicians of changes of conditions, including but not limited to any conditions that may affect mental, physical, or psychosocial well-being. No changes have been made to the new policy implemented. This will be completed by 04/19/2026. QAPI was completed by NHA, DON, and facility RN consultant, Director of Operations by 04/19/2026. This was communicated to the IDT team which includes but is not limited to the DON, ADON, MDS, RT, SSD, Medical Records, Director of Rehab, etc. on 04/19/2026. The Plan of Removal was confirmed for the IJ by monitoring from 04/18/2026 through 04/22/2026 as follows: In interviews on 04/19/2026 between 10:00 AM and 5:00 PM with licensed nurses and nursing staff who worked the 6:00AM-6:00PM, 6:00AM-2:00PM and 2:00PM-10:00PM shifts who were all knowledgeable of the step-by-step process for monitoring, identifying and reporting procedures for changes in condition to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the charge nurses and then following the chain of command for reporting which included ADON to DON to Administrator if concerns not resolved. The Wound Care Nurse, ADON, MDS Nurse and DON (who worked 06:00 AM -06:00 PM ) said any changes from a residents baseline clinical status would be considered a change in condition and included things like vital signs outside of parameter, refusals of medications, meals or other care, weight loss and or skin changes would all be examples of changes in condition to report to the residents physicians. All licensed nurses, RN A, LVN A, LVN B, (who worked 06:00 AM- 06:00 PM) and nursing staff, MA E (06:00 AM-02:00 PM), MA H (02:00 PM- 10:00 PM) , CNA F and CNA G (06:00 AM- 02:00 PM), gave examples of changes of condition that could include, refusing showers, medications, meals and or having pain, changes to skin or vital signs and said they would report per chain of command, which for the CNA's included reporting to charge nurse first and then to ADON/DON and then Administrator and for licensed nurses, who said they would report and changes in condition to the residents MD, RP and DON and document in the resident EMR. All licensed staff at that time said they would immediately report any changes in condition and follow up at the beginning and end of each shift and document all communications and reporting in the residents EMR and facility 24-hour shift to shift reports. All licensed nursing staff said they would check, verify, and clarify admission and physician orders and they would initiate SBAR for the specific resident change in condition and notify the MD and RP for the resident. In interviews on 04/20/2026 between 9:00 AM and 6:00 PM with licensed nurses and nursing staff who worked the 6:00AM-2:00PM and 2:00PM-10:00PM shifts who were all knowledgeable of the step-by-step process for monitoring, identifying and reporting procedures for changes in condition to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the charge nurses and then following the chain of command for reporting which included ADON to DON to Administrator if concerns not resolved. All nursing staff, RN C (06:00 AM-02:00 PM) , CNA I, CNA J, CNA K, CNA L (6:00 AM-02:00 PM), CNA M, CNA N, CNA O, MA F and AD/CNA P (02:00PM-10:00PM) gave examples of changes of condition that could include, refusing showers, medications, meals and or having pain, changes to skin or vital signs and said they would report per chain of command, which for the CNA's included reporting to charge nurse first and then to ADON/DON and then Administrator and for licensed nurses, who said they would report and changes in condition to the residents MD, RP and DON and document in the resident EMR. All licensed staff at that time said they would immediately report any changes in condition and follow up at the beginning and end of each shift and document all communications and reporting in the residents EMR and facility 24-hour shift to shift reports. All licensed nursing staff said they would check, verify, and clarify admission and physician orders and they would initiate SBAR for the specific resident change in condition and notify the MD and RP for the resident. In interviews conducted on 04/21/2026 between 8:00 AM and 6:00 PM with licensed nurses and nursing staff who worked the 6:00AM-2:00PM and 2:00PM-10:00PM shifts who were all knowledgeable of the step-by-step process for monitoring, identifying and reporting procedures for changes in condition to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the charge nurses and then following the chain of command for reporting which included ADON to DON to Administrator if concerns not resolved. All nursing staff, LVN G, RN D (06:00 AM- 02:00PM), CNA P, CNA Q, CNA R( 10:00 PM- 06:00 AM), CNA S, MA A, MA D ( 02:00 PM-10:00 PM) and DM (06:00 AM-06:00 PM)gave examples of changes of condition that could include, refusing showers, medications, meals and or having pain, changes to skin or vital signs and said they would report per chain of command, which for the CNA's included reporting to charge nurse first and then to ADON/DON and then Administrator and for licensed nurses, who said they would report and changes in condition to the residents MD, RP and DON and document in the resident EMR. All licensed staff at that time said they would immediately report any changes in condition and follow up at the beginning and end of each shift and document all communications and reporting in the residents EMR and facility 24-hour shift to shift reports. All licensed nursing staff said they would check, verify, and clarify admission and physician orders and they would initiate SBAR for the specific resident change in condition and notify the MD and RP for the resident. In interviews conducted on 04/22/2026 between 8:30 AM and 3:00 PM with licensed nurses and nursing staff who worked the 6:00AM-2:00PM, 2:00PM-10:00PM and 10:00PM-6:00AM shifts who were all knowledgeable of the step-by-step process for monitoring, identifying and reporting procedures for changes in condition to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the charge nurses and then following the chain of command for reporting which included ADON to DON to Administrator if concerns not resolved. All nursing staff, RN E, CNA T, (10:00 PM-06:00 AM) SW and DOR (06:00 AM-06:00 PM) gave examples of changes of condition that could include, refusing showers, medications, meals and or having pain, changes to skin or vital signs and said they would report per chain of command, which for the CNA's included reporting to charge nurse first and then to ADON/DON and then Administrator and for licensed nurses, who said they would report and changes in condition to the residents MD, RP and DON and document in the resident EMR. All licensed staff at that time said they would immediately report any changes in condition and follow up at the beginning and end of each shift and document all communications and reporting in the residents EMR and facility 24-hour shift to shift reports. All licensed nursing staff said they would check, verify, and clarify admission and physician orders and they would initiate SBAR for the specific resident change in condition and notify the MD and RP for the resident. Record reviews on 04/19/2026, 04/20/2026, 04/21/2026 and 04/22/2026 revealed nursing staff in-services with guidelines for notifying physicians of changes in condition, notifying the RD, notifying the DON and or ADON or designee and following physician orders which had been completed prior to any staff working as of 04/19/2026. The Administrator was informed the immediacy was removed on 04/22/2026 at 2:02PM. The facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #1) reviewed for nutrition status. 1. The facility failed to ensure Resident #1 did not have a significant weight loss of 19% due to losing 23lbs in 12 days. 2. The facility failed to provide Resident #1 with feeding and nutrition via her PEG tube. 3. The facility failed to ensure Resident #1 had dietary recommendations in place from her admission on [DATE] until 4/17/2026, the date of State Surveyor facility entrance. 4. The facility failed to ensure Resident #1 had weekly weights obtained per physician order. 5. The facility failed to address Resident #1's risk of impaired nutrition related to her newly inserted PEG tube status and therapeutic diet orders. An immediate Jeopardy (IJ) situation was identified on 04/18/2026. While the IJ was removed on 04/22/2026, the facility remained out of compliance scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for compromised nutrition, decline in function, unplanned weight changes, and actual harm. Findings Include: Record review of Resident #1's admission record dated 04/17/2026 revealed a-[AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Wernicke's encephalopathy (an acute life-threatening neurological emergency caused by a severe deficiency of thiamine [vitamin B1] which damages the brain), aneurysm ( a rare, localized, blood-filled bulge in the wall of carotid artery [major blood vessel located on either side of the neck, that supplies oxygen rich blood to the brain, neck and face] and can cause stroke like symptoms), dysphagia (difficulty swallowing) and anorexia (loss of appetite or inability to eat). Resident #1 did not have a diagnosis for her PEG tube (a soft flexible tube inserted through the abdomen directly into the stomach, used for long-term nutrition, hydration, and medication when oral intake is not possible). Record review of Resident #1's admission MDS assessment, dated 03/30/2026, revealed her BIMS score was 14 out of 15 indicating her cognition was considered intact. Review of Section I for Active Diagnoses revealed Resident #1 did not have an active diagnosis for her gastrostomy tube. Continued record review of section K Swallowing/Nutrition Status revealed Resident #1 was coded as having a swallowing disorder that included coughing or choking during meals or when swallowing medications and had a weight of 120lbs and a mechanically altered diet (a diet that required a change in texture of food or liquids.) Record review on 4/17/26 at 12:03 PM of Resident #1's hospital discharge summary revealed the following diet order: Discharge Orders: Regular Diet: Diet Texture: Pureed 4 Pureed for comfort, not sufficient for nutrition. (sic)Has PEG and should remain NPO (nothing by mouth) otherwise. Record review on 04/17/2026 at 12:07 PM of an undated, unsigned handwritten note in Resident #1's EMR revealed the following: PEG use (sic)tom@10 am. Pureed/thin (sic) liq diet (pleasure). Jevity 1.5 50 cc NG tube (Tube out). Record review on 04/17/2026 at 1:09 PM of Resident #1's physician order recap report revealed the following active order with a start date of 03/27/2026 and no end date: Regular diet Pureed Texture, regular/thin consistency, for pleasure food. And an active order with a start date of 04/02/2026 and no end date: Enteral feed order every shift. Flush enteral tube with 120 ml water q 8 hours to provide 360 ml water and with 30 ml of water before and after medication administration. Record review on 04/17/2026 at 1:15 PM of Resident #1's physician order report revealed Resident #1 had an active order dated 03/30/2026 for Consult with Registered Dietician for tube feeding management. Continued record review also revealed an active order dated 04/01/2026 with a start date of 04/02/2026 for Ensure Plus three times a day, 237 ml PO (by mouth) TID. The active order was 6 days after Resident #1 was admitted to the facility on [DATE]. Record review on 04/17/2026 at 1:22pm of Resident #1's Medication Administration record dated April 1, 2026, through April 30, 2026, revealed Ensure Plus three times a day, 237ml PO TID at 7 AM, 12 Noon and 6 PM. Continued record review revealed Resident #1 refused all three administration times on 8 days, (04/03/2026, 04/06/2026, 04/07/2026, 04/08/2026, 04/10/2026, 0 4/14/2026, 04/15/2026 and 04/16/2026). There were 3 days that there was no documentation of administration and the time slots were completely blank (04/04/2026, 04/11/2026 and 04/12/2026) and 2 days that staff documents at 6pm that Resident #1 was nauseated/vomited or asleep (04/09/2026 and 04/13/2026). Record review on 04/17/2026 at 5:05 PM of Resident #1's EMR for weights revealed a weight of 120.0 lbs., dated 04/03/2026 at 11:45 AM, 7 days after Resident #1's admission. The 04/03/2026 weight of 120.0lbs was crossed out with a single line by the DON on 04/16/2026 at 12:13 PM. The DON documented Correction. The second weight entry was dated 4/15/2026 at 12:15PM and a weight of 96.5lbs. Continued record review of the hospital admission records for Resident #1 revealed no weights in the documents sent to the facility. Observation and interview with Resident #1 on 04/17/2026 at 11:00 AM. She was seated in a wheelchair, at a table alone, in the common area located directly adjacent to the dining room with her breakfast tray was in front of her with a plate that was uncovered and appeared to have pureed eggs, a pureed dark colored substance and a smaller pureed tan colored substance. There was an uncovered bowl of oatmeal and 2 clear colored drink cups that were full of liquid and covered. The residents' utensils had been unwrapped and were clean of any food debris and an unused napkin sat to the right side of the tray. State surveyor introduced herself to Resident #1 who said the tray was her breakfast tray and she needed help eating it, but no one had come to help her eat her breakfast tray. The State Surveyor remained with resident and requested a passerby to get the DON. Continued observation and interview with Resident #1 with DON present on 04/17/2026 at 11:03 AM the DON said she did not know why the resident was seated in front of her uncovered, uneaten breakfast tray and would have to get the nurse. While the DON was at the table with the resident, surveyor asked the resident again, if she was hungry and Resident #1 replied, yes. The DON said she was going to get the residents nurse and or CNA. Surveyor remained with Resident #1. Continued observation and interview with Resident #1 on 04/17/2026 at 11:08 AM with RN A who said they were the nurse assigned to Resident #1 and did not know why she was still seated in front of her breakfast tray or why the breakfast tray remained uncovered and not eaten. RN A went to look for CNA E who was assigned to Resident #1. Surveyor remained with Resident #1. Continued observation and interview with Resident #1 on 4/17/26 at 11:23 am the facility Receptionist passed by and offered to reheat Resident #1's breakfast tray and assist her with feeding. The Receptionist said she was not sure where RN A or CNA E were, and just as the receptionist completed reheating Resident #1's breakfast tray, RN A returned and said he could not locate CNA E. RN A said he would take over from the Receptionist, and he would feed Resident #1. RN A said he was not aware that Resident #1 had not eaten breakfast. In a telephone interview on 04/17/2026 at 12:20 PM with the RD, who said their first visit to the facility was on 04/14/2026 and they were in the process of completing the evaluation for Resident #1. The RD said they were not familiar with Resident #1 and was not sure what Resident #1's weight was. The RD said they could complete evaluations remotely and had evaluated Resident #1 in person earlier that week. The RD said they usually evaluated new admission and readmission residents as well as residents with gastrostomy tubes, wounds, dialysis, or other risk factors. The RD said they usually completed a monthly evaluation of the resident census and conducted evaluations PRN. In a follow up observation and interview with Resident #1 on 04/17/2026 at 1:44 PM, she said she had not had much of an appetite over the last month and had a tube placed in her stomach while she was in the hospital. Resident #1 lifted her gown and exposed a gastrostomy tube. Resident #1 said staff pushed water through her tube daily, but she did not receive any medications or feeding formulas through the tube since she was admitted to the facility. Resident #1 said she could swallow and did not have pain when she swallowed, but the food sometimes seemed like it got stuck. Resident #1 said sometimes she did not like the mushy baby food the facility served. Resident #1 said some of the food served resembled dog food and she would eat what she liked and if she did not like the look, smell, or taste of the food she was not going to eat it. Resident #1 said the hospital would give her a milk-like formula through a tube that went from her nose to her stomach (NG Tube) and before she got to the facility, the hospital removed that tube from her nose and put the new tube directly into her stomach. In an interview with RN A on 04/17/2026 at 1:52 PM, who said they did not know Resident #1 was not taking her Ensure supplement until 04/17/2026, after the State Surveyor arrived at the facility. RN A said he had not yet reported this to the NP or MD. In an interview with the DON on 04/17/2026 at 1:57 PM, the DON stated she did not know Resident #1 had no enteral feeding formula order since her admission on [DATE] and she did not know Resident #1 was refusing her nutritional supplements, or meals. The DON said she would have notified the NP/MD immediately, so she could have obtained appropriate orders for Resident #1 if she had been notified of the issues and refusals, but she knew nothing about them. In an interview with MA C on 04/17/2026 at 2:00 PM, who said Resident #1 had not really been taking her Ensure supplement since the first day of admission, because she could not swallow. Interview with MA D on 04/17/2026 at 2:39 PM, who said Resident #1 regularly refused all of her medications and supplements and just would not take anything orally since she admitted to the facility. MA D said she did not know if Resident #1 had lost weight and did not know if Resident #1was refusing her meals but would not be surprised. Telephone interview with Resident #1's RP on 04/17/2026 at 3:00 PM, who said Resident #1 had not been eating after the aneurysm and the hospital suspected she had a stroke. The RP said Resident #1 lost the use of her right side which included her right arm and hand and had difficulty feeding herself. The RP said on at least 2 separate occasions within the last week, they were alarmed and angered Resident #1 was seated in front of various meal trays that had not been eaten and had no staff to help her eat. The RP said they confronted RN A about the issue the other day and was told by RN A Resident #1 needed to learn how to use her left hand to feed herself so she could go back home. The RP said they told RN A Resident #1 was right-handed prior to her illness, hospitalization, and surgery and needed help regardless because she was never left-handed. Resident #1's RP said Resident #1 had the G-tube placed while she was hospitalized because she was not eating enough to sustain herself. Resident #1's RP said they had not been notified that Resident #1 was refusing medications and nutritional supplements. During a telephone interview with the NP on 04/17/2026 at 3:06 PM she stated that Resident #1's actual enteral feeding formula order would normally come from the hospital discharge records but she was told by facility staff there were none, so she ordered an RD consultation to ensure the residents' caloric needs came from the dietician. The NP said she knew nothing about Resident #1's weight loss or refusals of nutritional supplements and had been told Resident #1 was tolerating a puree diet. The NP said she would have provided other orders if she had been informed of Resident #1's refusals. In a telephone interview with MD/Medical Director on 04/17/2026 at 4:07pm who stated they were never notified by facility staff that Resident #1 was not drinking her nutritional supplement, weight loss or that there were no orders for enteral feeding formula for Resident #1. The MD said the first time she rounded and saw Resident#1 she had a pureed meal tray and she was told by facility staff resident was tolerating the pureed diet. The MD said it would have been an easy fix to ensure Resident #1 had proper nutritional intake since she had a G-tube. The MD said it was a facility system failure all the way around and that there had been a recent change of ownership on or around 04/01/2026. In an interview with the DON on 04/18/2026 at 10:36AM, she said Resident #1 was supposed to have weekly weights upon admission and it just had not gotten done weekly due to changes and consistency issues with the CNA's completing the weights. The DON said she crossed out Resident #1's initial weight of 120 lbs on 04/03/2026 in the EMR because she just did not believe that was an accurate weight. When asked if she knew what Resident #1's current weight was she said she did not know. When asked if she knew what Resident #1's admission weight was, she said she did not know. When asked who was supposed to be completing the weekly weights for residents she said she did not know who was responsible for that duty with this company. Observation and interview with CNA F of attempt to weight Resident #1 on 04/18/2026 at 10:42 AM, CNA F said she was new and normally she would look for the weight of the wheelchair that would be written somewhere on the chair and subtract that from whatever the total weight on the scale was, and the remaining number would be the resident's weight. CNA F said she had no formal training at this facility on how to weigh a resident. She said she did not know if there was someone specifically assigned to obtain resident weights. The wheelchair Resident #1 was seated in at that time, did not have a weight for the chair located anywhere on the chair and Resident #1 declined to be transferred out of the wheelchair. CNA F was unable to weigh the wheelchair separately and Resident #1 declined to be weighed at that time. Record review on 04/18/2026 at 11:00 AM of RD recommendations, dated 04/17/2026, revealed the following: Dietary Recommendations:continue weekly weights to monitor weight trend.MD to consider D/C ensure TIDMD order for Jevity 1.5 continuous overnight at 55cc/hr x 10 hours (provides 550cc formula: 824kcal, 35g protein, 418cc water)Start TF at slow rate (25-30ml/hr) and increase 10ml/hr every 2 hoursRefer to MD for consult of protein-calorie malnutrition dx. Record review on 04/18/2026 at 1:44 PM of Resident #1's physician order report revealed an order, dated 4/17/2026, for Mirtazapine Oral tablet 15 mg. Give 1 tablet by mouth for prophylaxis related to her history of anorexia. There was no order to give the appetite stimulant medication through her gastrostomy tube. Record review on 04/18/2026 at 1:45 PM of nursing progress note, dated 4/18/26, revealed Resident #1 was initiated on continuous enteral feeding via PEG tube this shift per MD order. Feeding (Jevity 1.5) started at ordered initial rate of 25mL/hr. Rate titrated incrementally as ordered to current rate of 55mL/hr under nurse supervision. Record review of the facility policy procedure titled Nutrition (Impaired)/ Unplanned Weight Loss - Clinical Protocol and dated as revised September 2017 revealed in part: Nutrition (Impaired)/Unplanned Weight Loss -Clinical ProtocolAssessment and RecognitionThe nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time.The staff and physician will define the individual's current nutritional status(weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that maybe causing weight gain or increasing the risk of anorexia or weight loss.The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. This was determined to be an Immediate Jeopardy (IJ) on 04/18/2026 at 2:56 PM. The Administrator was notified. The Administrator was provided with the IJ template on 04/18/2026 at 2:56 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 04/19/2026 at 11:07 AM: PLAN OF REMOVAL:F 692 Name of Facility:Date: 04/19/2026According to the IJ Template, the facility failed to maintain acceptable parameters of nutritional status such as usual body weight or desirable body weight range for Resident #1 who lost 23.5 pounds in 12 days. She averaged 120 lbs. prior to admission and weighed 96.5 lbs. on 04/15/2026. This is a 19% weight loss in 12 days. Immediate Action: Corrective Action:Registered Dietician has completed a comprehensive nutritional assessment of Resident #1 and has recommended appropriate enteral feeding product. The physician was notified and the order was given and implemented. The CNA received training with the DON, or designee, on 04/18/2026, in regard to how to weigh a resident. Identification of Others The DON, or designee, completed an audit for all other residents with an enteral feeding order to verify that the order is complete, accurate, timely and implemented and that the residents are receiving their ordered enteral feeding product. It was verified that the current residents with enteral tube feeding are receiving the correct product at the correct rate by 04/19/2026. There were no other deficiencies found. System Changes IDT and nursing staff were educated on nutrition and weight management system on 04/19/2026 by the designee. Facility has recently been acquired, as of 04/01/2026, and the IDT was educated to the SNF Clinical system regarding the weight management system which is utilized by the SNF. The facility did not utilize this system prior. The NHA or designee provided the education to the IDT team which includes but is not limited to the DON, ADON, MDS, RT, SSD, Medical Records, Director of Rehab, etc. Record reviews on 04/19/2026, 04/20/2026, 04/21/2026 and 04/22/2026 revealed the IDT and nursing staff in-services with guidelines for nutrition and weight management which had been completed Registered Dietician educated by the facility RN consultant, or designee, on reviewing residents monthly that are receiving enteral tube feeding on 4/18/2026. The Registered Dietician is contracted through Company A. The facility currently has a consultant dietician. This was completed on 04/18/2026. IDT were educated by the NHA, or designee, on the importance of obtaining accurate resident weight per physician order/facility policy by 04/19/2026. Scale will be correctly calibrated per manufacturers recommendations. The Director of Plant Operations, or designee, will be completed per recommendations. Director of Plant Operations has confirmed calibration schedule with the manufacturer by 04/19/2026. Record review of manufacturers recommendations on 04/19/2026 revealed facility had monthly scale service and calibration per manufacturer recommendations. The ADON, or designee, educated nursing staff on timely physician notification of any significant weight loss by 4/19/2026.All nursing staff who cannot complete training by 4/19/2026 will not be placed on the schedule until training is completed. Record reviews on 04/19/2026, 04/20/2026, 04/21/2026 and 04/22/2026 revealed the IDT and nursing staff in-services with guidelines for timely physician notification of any significant weight loss which had been completed. Monitoring The facility RN consultant, or designee will complete training for monitoring physician orders daily (five days a week) to include but not limited to enteral tube feeding orders via the daily clinical meeting process by 4/19/2026. DON, or designee, will audit daily (five days a week) to ensure that the correct enteral feeding product is hanging and being administered as per order to include the correct flow rate. DON, or designee, will monitor physician orders daily (five days a week) to include but not limited to enteral tube feeding orders via the daily clinical meeting process. DON, or designee, will audit daily (five days a week) to ensure that the correct enteral feeding product is hanging and being administered as per order to include the correct flow rate. DON, or designee, will audit weights per physician order and facility policy and report results of all audits to QAPI monthly. The MD was notified of the IJ by NHA and DON on 4/18/2026. IDT (which includes but is not limited to the DON, ADON, MDS, RT, SSD, Medical Records, Director of Rehab, etc) and nursing staff were educated on the nutrition and weight management system on 4/19/2026 by the Administrator or designee. Facility has recently been acquired, as of 4/1/2026, and the IDT was educated to the SNF Clinical system regarding the weight management system which is utilized by SNF. The facility did not utilize this system prior. Upon review it is evidenced that the facility did not follow any weight loss management system prior to the acquisition. This is evidenced by missing weights, incorrect weights, lack timely entry, weights not being completed weekly, and orders not being followed, and physician notifications. QAPI was completed by NHA, DON, and facility RN consultant, Director of Operations by 4/19/2026. This was communicated to the IDT team which includes but is not limited to the DON, ADON, MDS, RT, SSD, Medical Records, Director of Rehab, etc. on 4/19/2026. The Plan of Removal was confirmed for the IJ by monitoring from 04/18/2026 through 04/22/2026 as follows: Interview with IDT which included NHA, DON, ADON, DOR, MDS, Maintenance Director and SSD on 04/19/2026 at 10:09 AM on the new SNF nutrition and weight management systems. They were all knowledgeable of the step-by-step process for monitoring, identifying, and reporting the procedures outlined in each system that included following physician orders, obtaining accurate weights, scale calibration and obtaining and following RD consultations and recommendations. In interviews on 04/19/2026 between 10:00AM and 5:00PM with licensed nurses and nursing staff who worked the 6:00AM-6:00PM, 6:00AM-2:00PM and 2:00PM-10:00PM shifts who were all knowledgeable of the step-by-step process for monitoring, identifying and reporting procedures for weight loss, weighed residents and changes in condition to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the charge nurses and then following the chain of command for reporting which included the ADON to the DON to the Administrator if concerns not resolved. The Wound Care Nurse, ADON, MDS Nurse and DON (who worked 06:00 AM -06:00 PM ) said any changes from a residents baseline clinical status would be considered a change in condition and included things like vital signs outside of parameter, refusals of medications, meals or other care, weight loss and or skin changes would all be examples of changes in condition to report to the residents physicians. They said scales X2 at the facility (wheelchair/walk-on scale and Hoyer) all had to be serviced and calibrated quarterly and PRN. All licensed nurses, RN A, LVN A, LVN B, (who worked 06:00 AM- 06:00 PM) and nursing staff, MA E, (06:00 AM-02:00 PM), MA H, (02:00 PM- 10:00 PM) CNA F and CNA G, (06:00 AM- 02:00 PM), gave examples of changes of condition that could include, weight loss and were able to articulate the steps for following physician orders and accurately obtaining resident weights using any of the 2 scales on-site at the facility. All licensed staff at that time said they would immediately report any changes in condition and follow up at the beginning, and end of each shift, and document all communications and reporting in the residents EMR and facility 24-hour shift to shift reports. All licensed nursing staff said they would check, verify, and clarify admission and physician orders and they would initiate SBAR for the specific resident change in condition and notify the MD and RP accordingly. All nursing staff said that new and readmission residents required weekly weights X 4 weeks and following up to ensure residents have the correct diet and are eating meals as ordered. Interview with the ADON and the DON on 4/20/2026 who were able to articulate and show audits for how they were monitoring physician orders daily (five days a week) to include but not limited to enteral tube feeding orders via the daily clinical meeting process and ensuring that the correct enteral feeding product is hanging and being administered as per order to include the correct flow rate and an audit of resident weights per physician order and following the facility policy. In interviews on 04/20/2026 between 9:00 AM and 6:00 PM with licensed nurses and nursing staff who worked the 6:00AM-2:00PM and 2:00PM-10:00PM shifts who were all knowledgeable of the step-by-step process for monitoring, identifying and reporting procedures for weight loss, weighing residents and changes in condition to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the charge nurses and then following the chain of command for reporting which included ADON to DON to Administrator if concerns not resolved. The Wound Care Nurse, ADON, MDS Nurse and DON (who worked 06:00 AM- 06:00 PM) said any changes from a residents baseline clinical status would be considered a change in condition and included things like vital signs outside of parameter, refusals of medications, meals or other care, weight loss and or skin changes would all be examples of changes in condition to report to the residents physicians. They said scales X2 at the facility (wheelchair/walk-on scale and Hoyer) all had to be serviced and calibrated quarterly and prn. All licensed nurses, and nursing staff, RN C, (06:00 AM-02:00 PM) CNA I, CNA J, CNA K, CNA L, CNA M, (6:00 AM-02:00 PM), CNA N, CNA O, MA F and AD/CNA P (02:00PM-10:00PM) gave examples of changes of condition that could include, weight loss and were able to articulate the steps for following physician orders and accurately obtaining resident weights using any of the 2 scales on-site at the facility. All licensed staff at that time said they would immediately report any changes in condition and follow up at the beginning, and end of each shift, and document all communications and reporting in the residents EMR and facility 24-hour shift to shift reports. All licensed nursing staff said they would check, verify, and clarify admission and physician orders and they would initiate SBAR for the specific resident change in condition and notify the MD and RP accordingly. All nursing staff said that new and readmission residents required weekly weights X 4 weeks and following up to ensure residents have the correct diet and are eating meals as ordered. They said scales X2 at the facility (wheelchair/walk-on scale and Hoyer) all had to be serviced and calibrated quarterly and prn. In interviews conducted on 04/21/2026 between 8:00 AM and 6:00 PM with licensed nurses and nursing staff who worked the 6:00AM-2:00PM and 2:00PM-10:00PM shifts who were all knowledgeable of the step-by-step process for monitoring, identifying and reporting procedures for weight loss, weighing residents and changes in condition to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the charge nurses and then following the chain of command for reporting which included ADON to DON to Administrator if concerns not resolved. All nursing staff, LVN G, RN D, (06:00 AM- 02:00PM), CNA P, CNA Q, CNA R( 10:00 PM- 06:00 AM), CNA S, MA A, MA D ( 02:00 PM-10:00 PM) and DM (06:00 AM-06:00 PM) gave examples of changes of condition that could include, weight loss and were able to articulate the steps for following physician orders and accurately obtaining resident weights using any of the 2 scales on-site at the facility. All licensed staff at that time said they would immediately report any changes in condition and follow up at the beginning, and end of each shift, and document all communications and reporting in the residents EMR and facility 24-hour shift to shift reports. All licensed nursing staff said they would check, verify, and clarify admission and physician orders and they would initiate SBAR for the specific resident change in condition and notify the MD and RP accordingly. All nursing staff said that new and readmission residents required weekly weights X 4 weeks and following up to ensure residents have the correct diet and are eating meals as ordered. They said scales X2 at the facility (wheelchair/walk-on scale and Hoyer) all had to be serviced and calibrated quarterly and PRN. In interviews conducted on 04/22/2026 between 8:30 AM and 3:00 PM with licensed nurses and nursing staff who worked the 6:00AM-2:00PM, 2:00PM-10:00PM and 10:00PM-6:00AM shifts who were all knowledgeable of the step-by-step process for monitoring, identifying and reporting procedures for changes in condition to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the charge nurses and then following the chain of command for reporting which included ADON to DON to Administrator if concerns not resolved. All nursing staff, RN E, CNA T, (10:00 PM-06:00 AM) SW and DOR (06:00 AM-06:00 PM) gave examples of changes of condition that could include weight loss and were able to articulate the steps for following physician orders and accurately obtaining resident weights using any of the 2 scales on-site at the facility. They said scales X2 at the facility (wheelchair/walk-on scale and Hoyer) all had to be serviced and calibrated quarterly and prn. All licensed staff at that time said they would immediately report any changes in condition and follow up at the beginning, and end of each shift, and document all communications and reporting in the residents EMR and facility 24-hour shift to shift reports. All licensed nursing staff said they would check, verify, and clarify admission and physician orders and they would initiate SBAR for the specific resident change in condition and notify the MD and RP accordingly. All nursing staff said that new and readmission residents required weekly weights X 4 weeks and following up to ensure residents have the correct diet and are eating meals as ordered. The Administrator was informed the immediacy was removed on 04/22/2026 at 2:02PM. The facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 14 residents (Resident#1) reviewed for accuracy of assessments. The facility failed to ensure Resident#1's admission MDS assessment accurately reflected her gastrostomy tube status. This failure could place residents at risk of receiving inadequate care and services. The findings include: Record review of Resident #1's admission record, dated 04/17/2026, revealed a-[AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Wernicke's encephalopathy (an acute life-threatening neurological emergency caused by a severe deficiency of thiamine [vitamin B1] which damages the brain), aneurysm ( a rare, localized, blood-filled bulge in the wall of carotid artery [major blood vessel located on either side of the neck, that supplies oxygen rich blood to the brain, neck and face] and can cause stroke like symptoms), dysphagia (difficulty swallowing) and anorexia (loss of appetite or inability to eat). Resident #1 did not have a diagnosis for her PEG tube (a soft flexible tube inserted through the abdomen directly into the stomach, used for long-term nutrition, hydration, and medication when oral intake is not possible). Record review of Resident #1's admission MDS assessment, dated 03/30/2026, revealed her BIMS score was 14 out of 15, which indicated her cognition was considered intact. Section I for Active Diagnoses revealed Resident #1 did not have an active diagnosis for her gastrostomy tube. Section K Swallowing/Nutrition Status revealed Resident #1 was coded as having a swallowing disorder that included coughing or choking during meals or when swallowing medications and had a weight of 120 lbs. and a mechanically altered diet (a diet that required a change in texture of food or liquids.) Record review of Resident #1's hospital discharge summary revealed the following diet order: Discharge Orders: Regular Diet: Diet Texture: Pureed 4 Pureed for comfort, not sufficient for nutrition. (sic) Has PEG and should remain NPO (nothing by mouth) otherwise. Record review on of Resident #1's physician order recap report revealed the following active order with a start date of 03/27/2026 and no end date: Regular diet Pureed Texture, regular/thin consistency, for pleasure food. And an active order with a start date of 04/02/2026 and no end date: Enteral feed order every shift. Flush enteral tube with 120 ml water q 8 hours to provide 360 ml water and with 30 ml of water before and after medication administration. Observation and interview with Resident #1 on 04/17/2026 at 11:00 AM revealed she was seated in a wheelchair, at a table alone, in the common area located directly adjacent to the dining room, her breakfast tray was in front of her with a plate that was uncovered and appeared to have pureed eggs, a pureed dark colored substance and a smaller tan colored substance. There was an uncovered bowl of oatmeal and 2 clear colored drink cups full of liquid and covered. The residents' utensils were unwrapped and were clean of any food debris and an unused napkin sat to the right side of the tray. State surveyor introduced herself to Resident #1 who said the tray was her breakfast tray and she needed help eating it, but no one had come to help her eat her breakfast tray. The State Surveyor remained with the resident and requested a passerby to get the DON. In a follow up interview and observation with Resident #1, in her room, on 04/17/2026 at 1:44 PM, she said she had not had an appetite over the last month or so and had a tube placed in her stomach when she was in the hospital. Resident #1 lifted her gown and exposed a gastrostomy tube. Resident #1 said that staff pushed water through her tube daily, but she did not receive any medications or feeding formulas through the tube. In an interview with the DON on 04/17/2026 at 2:12 PM, the DON said the admitting nurse was responsible for entering the resident diagnoses and the MDS should also review admission records and the resident clinical information to obtain diagnoses. The DON said the MDS nurse should also interview residents at the bedside or in person whenever possible, to help ensure accuracy of assessments. The DON said she was not aware Resident #1 had no diagnosis entered in her EMR for her gastrostomy status. The DON said if a resident did not have the correct diagnoses documented it could put them at risk for not receiving the appropriate care and treatments and the MDS assessments should be coded correctly for every resident. The DON said the MDS nurse was responsible for ensuring resident diagnoses were accurate and correct and did not know why Resident #1's diagnoses and admission assessment were incorrect. In an interview with the Administrator on 04/17/2026 at 5:30 PM, she said her expectation was the resident MDS assessments to be coded correctly and all of the facility residents should have accurate and current diagnoses documented. The Administrator said she was unaware Resident #1 did not have a diagnosis for her gastrostomy tube in her EMR and she was not sure who was responsible for entering resident diagnoses. The Administrator said she would add Resident #1's gastrostomy tube status to her diagnosis list in the EMR. The Administrator was part of the new company who acquired the facility and said they were working on correcting and establishing various systems that had not been in place. Interview with MDS nurse on 04/22/2026 at 1:11 PM, who said Resident #1's diagnosis had been corrected in the EMR, after the State Surveyor intervention. The MDS Nurse said whichever nurse admitted Resident #1 would have been responsible for entering resident diagnoses, but she did not know who the nurse was. The MDS Nurse said Resident #1 should have had a diagnosis for gastrostomy status and tube because she had one and the omission of the diagnosis on her admission MDS was an oversight. The MDS Nurse said if a resident did not have accurate diagnoses, it could affect reimbursement and could result in a resident not receiving the appropriate care. The MDS Nurse said she interviewed and observed Resident #1 but somehow missed coding her for her gastrostomy tube. The MDS Nurse said she would modify Resident #1's MDS by the end of the business day. The MDS Nurse said she used the RAI manual as the policy and procedure she followed for accuracy in completing the MDS. Record review of CMS's RAI Version 3.0 Manual, dated October 2025, revealed in part: Section I: Active Diagnoses Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet resident's medical, nursing, mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 14 residents (Resident #1) reviewed for care plans. 1. The facility failed to develop or implement a care plan for Resident #1 to address the resident's gastrostomy tube status. 2. The facility failed to develop or implement a care plan for Resident #1 to address the residents' diet. These failures could place residents at risk of not receiving care and services tailored to their identified needs. Findings include: Record review of Resident #1's admission record, dated 04/17/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Wernicke's encephalopathy (an acute life-threatening neurological emergency caused by a severe deficiency of thiamine [vitamin B1] which damages the brain), aneurysm ( a rare, localized, blood-filled bulge in the wall of carotid artery [major blood vessel located on either side of the neck, that supplies oxygen rich blood to the brain, neck and face] and can cause stroke like symptoms), dysphagia (difficulty swallowing) and anorexia (loss of appetite or inability to eat). Resident #1 did not have a diagnosis for her PEG tube (a soft flexible tube inserted through the abdomen directly into the stomach, used for long-term nutrition, hydration, and medication when oral intake is not possible). Record review of Resident #1's admission MDS assessment, dated 03/30/2026, revealed her BIMS score was 14 out of 15, which indicated her cognition was considered intact. Section I for Active Diagnoses revealed Resident #1 did not have an active diagnosis for her gastrostomy tube. Section K Swallowing/Nutrition Status revealed Resident #1 was coded as having a swallowing disorder which included coughing or choking during meals or when swallowing medications and had a weight of 120 lbs. and a mechanically altered diet (a diet that required a change in texture of food or liquids.) Record reviewResident #1's hospital discharge summary revealed the following diet order: Discharge Orders: Regular Diet: Diet Texture: Pureed 4 Pureed for comfort, not sufficient for nutrition. (sic) Has PEG and should remain NPO (nothing by mouth) otherwise. Record review on 04/17/2026 at 1:09 PM of Resident #1's physician order recap report revealed the following active order, with a start date of 03/27/2026 and no end date: Regular diet Pureed Texture, regular/thin consistency, for pleasure food. And an active order with a start date of 04/02/2026 and no end date: Enteral feed order every shift. Flush enteral tube with 120 ml water q 8 hours to provide 360 ml water and with 30 ml of water before and after medication administration. Record review on 04/17/2026 at 2:00 PM of Resident #1's comprehensive care plan, dated as initiated and revised on 04/18/2026, revealed the following: [Resident #1] has a G-tube r/t oropharyngeal dysphagia (difficulty initiating a swallow causing food to stick to the throat) following recent aneurysm and severe protein calorie malnutrition. Currently receiving a puree diet for pleasure feeds with refusals to eat at times. [Resident #1] is NPO for main source of nutrition. Continued record review revealed the following entry, dated as initiated on 04/17/2026 and revised on 04/17/2026, [Resident #1] is receiving a mechanically altered diet due to oropharyngeal dysphagia. Observation and interview with Resident #1 on 04/17/2026 at 11:00 AM, revealed she was seated in a wheelchair, at a table alone, in the common area located directly adjacent to the dining room with her breakfast tray in front of her with a plate which was uncovered and appeared to have pureed eggs, a pureed dark colored substance and a smaller pureed tan colored substance. There was an uncovered bowl of oatmeal and 2 clear colored drink cups that were full of liquid and covered. The residents' utensils were unwrapped and were clean of any food debris and an unused napkin sat to the right side of the tray. State surveyor introduced herself to Resident #1 who said the tray was her breakfast tray and she needed help eating it, but no one had come to help her eat her breakfast tray. The State Surveyor remained with resident and requested a passerby to get the DON. During an interview and observation with Resident #1, in her room, on 04/17/2026 at 1:44 PM, she said she had not had an appetite over the last month or so and had a tube placed in her stomach when she was in the hospital. Resident #1 lifted her gown and exposed a gastrostomy tube. Resident #1 said staff pushed water through her tube daily, but she did not receive any medications or feeding formulas through the tube. In an interview with the DON on 04/17/2026 at 2:12 PM, the DON said the RN admitting the resident was responsible for initiating a resident care plan. The DON said the MDS Nurse was responsible for the comprehensive care plans. The DON said the MDS Nurse should have reviewed the admission records and the resident clinical information to obtain the information needed to complete the MDS and care plans. The DON said she was not aware Resident #1 had no care plan for her gastrostomy tube, no care plan for her diet, and no care plan for her enteral feeding status. The DON said up until the recent facility company change, she was unable to monitor or keep up with all of the clinical systems like checking new admission paperwork for diagnoses and care plans. The DON said if a resident did not have a care plan, it could put them at risk of not receiving the appropriate care and treatments. The DON said Resident #1 should have had a care plan for her gastrostomy tube status, and diet upon admission and did not know why she had not already been care planned for those needs. The DON said the IDT was responsible for reviewing and updating resident care plans. The DON said there had been inconsistencies within the IDT, and they had not been able to meet or conduct reviews due to the recent facility changes in ownership and staff changes. The DON said she was part of the IDT but had not had a chance to review Resident #1's care plans. In an interview with the Administrator on 04/17/2026 at 5:30 PM, she said her expectation was all of the facility residents should have accurate and current care plans. The Administrator said she was unaware Resident #1 did not have a care plan for her gastrostomy tube, or diet in her EMR. The Administrator said the nurses were responsible for initiating the care plans and the MDS Nurse was responsible for updating the comprehensive care plans. The Administrator said she was part of the new company which acquired the facility and they were working on correcting and establishing various systems that had not been in place. Interview with the MDS nurse on 04/22/2026 at 1:11 PM, who said Resident #1's gastrostomy tube status and diet should have been care- planned from her admission on [DATE]. The MDS Nurse said she updated Resident #1's comprehensive care plans the same day the state surveyor entered the facility and began asking questions about Resident #1's gastrostomy status and diet orders. The MDS Nurse said whichever nurse admitted Resident #1 would have been responsible for initiating the care plans, but she did not know who the nurse was. The MDS Nurse said she updated resident care plans whenever she completed the residents' assessments. The MDS Nurse said if a resident did not have a comprehensive person-centered care plan, it could result in a resident not receiving the appropriate care. The MDS Nurse said there had been a recent change in company ownership, and they were getting all of the systems, which included care plans, back on track. Record review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, dated Revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, including: (3) which professional services are responsible for each element of care.c. includes the resident's stated goals upon admission and desired outcomes.d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions. 12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the residents' condition.b. when the desired outcome is not met.c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review , the facility failed to report the results of an investigation in accordance with State Law including the State Survey Agency within 5 working days of the incident for 2 of 2 (Resident #1 and Resident #2) incidents reviewed for reporting. The facility failed to ensure the Administrator reported the results of an investigation within 5 days to the State Survey Agency. This failure could place residents at risk if appropriate corrective actions are not taken. Record review completed on 03/31/2026 at 12:13 p.m., of the TULIP system revealed that a PIR, Form 3613-A, was not filed in the system for two separate incidents reported by the facility on 3/18/2026 to the Complaint and Incident Intake.During an interview on 4/2/2026 at 9:56 a.m., the Director of Operations stated his team was trying to locate the PIRs, but the former administrator may have shredded them. The Director of Operations stated his company acquired the facility the day before on 4/1/2026. During an interview on 4/2/2026 at 10:37 a.m., the Administrator stated her first day of employment at the facility was yesterday, 4/1/2026. The Administrator stated she would try her best to locate the PIR documents. The Administrator stated that regional personnel were in the building and would help her try to locate the information. During an interview on 4/2/2026 at 10:40 a.m., the DON stated the facility went through a change of ownership yesterday and was now owned by a new company. The DON stated she was not responsible for PIRs. The DON stated the former administrator handled PIRs on his own. The DON stated she did not have access to TULIP. During an interview on 4/2/2026 at 11:14 a.m., the Regional NHA stated she was not from Texas, and her facility was in Colorado. The Regional NHA stated she did not have access to TULIP, and the former administrator was not willing to assist with locating the PIRs. During an interview on 4/2/2026 at 1:10 p.m., the Social Worker stated she was not responsible for submitting the PIRs. The Social Worker stated she worked at the facility for two weeks. During an interview on 4/2/2026 at 1:19 p.m., RN A stated she worked for the facility since August 2025 and was not responsible for submitting PIR's. During an interview on 4/2/2026 at 2:13 p.m., RN B stated she had worked at the facility since late 2023. RN B stated she was not responsible for PIR's. RN B stated 4/2/2026 was the Administrator's first day at the facility.During an interview on 4/2/2026 at 3:17 p.m., the Administrator stated the former administrator was not willing to cooperate with locating the PIR's. The Administrator stated she did not have access to TULIP. The Administrator stated there was not a sister facility that could assist. The Administrator stated she was a NHA in Colorado and was in the process of getting her license as a Nursing Administrator in Texas. The Administrator stated that if Texas was like Colorado in terms of PIRs, the PIR should be submitted to the State within five days from the date reported to the State. The Administrator stated she was not aware there were incomplete investigations pending a Provider Investigation due to her first day of employment was yesterday, 4/1/2026. The Administrator stated there was not a process in place to locate pending investigations with the acquisition of the facility. The Administrator stated that it was a process that needed to be looked into. Record review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating- F609, dated 2001 and revised in September 2022, read .1. Within five (5) calendar days of the incident, the administrator will provide a follow-up investigation report.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician of G- tube dysfunction or malfunction for 1 of 4 residents reviewed for physician notification (Resident #1). The facility failed to immediately consult with the resident's physician when facility staff did not implement physician order due to the inadequate supply of adnominal binder to protect G-tube and G-tube site for 1 of 4 residents reviewed for physician notification (Resident #1). The facility failed to notify the resident's physician of complications related to Resident# 1 G-tube site pain and administering medications to Resident #1 via the G-Tube. The failure resulted in LVN V administering medications by plunger pushing the medications with force into Resident #1 gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms associated G-Tube blockage and Aspiration (occurs when liquid or food enters the lungs). The facility failed to notify the physician that physician's order for an abdominal binder indicated to prevent complications of gastrostomy tube was not implemented. The facility failure resulted in Resident #1 requiring discharge to the hospital for G-Tube replacement. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were informed on 03/27/2024 at 5:40pm. The IJ was lowered on 03/29/23 at 1:33pm, the facility remained out of compliance at a scope of pattern and a severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failures have the potential to cause significant complications, including infections, aspiration, hospitalization s, or death, in residents with gastrostomy tubes. Findings included: Record review of Resident #1's face sheet dated 03/25/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old female. Resident #1 had a diagnosis of Gastrostomy Status (the creation of an artificial external opening into the stomach for nutritional support or gastric decompression via a G- Tube) and Gastro-Esophageal Reflux Disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus) dated 08/26/2023. Record review of clinical record, Resident #1's Care Plan revealed that Resident #1 require to have an abdominal feeding tube. Care Plan Goal: Resident was to remain free of side effect of complication Resident insertion site will be free of sign and symptoms of infection. Interventions Task: Check tube placement and gastric contents/residual volume per facility protocol and record (policy). Monitor/document/ report tube dysfunction or malfunction, abdominal pain, and infection at the tube site provide local care to G-Tube site as ordered administer medication as ordered. Record review of clinical record, Resident #1's MDS revealed that Resident #1 required abdominal feeding tube. Record review of Resident #1's physician's order summary report revealed the following order: every shift for flush feeding tube with 30ml(cc) of water before and after administration of medication pass. clean and change dressing one time a day. Apply abdominal binder, order dated as of 12/07/2023. Record review of clinical record, Resident #1's MAR/TAR revealed no documentation that the physician order for abdominal binder had been followed and implemented from 12/07/2023 thru 03/25/2024. Observation made on 03/25/2024 at 10:30am revealed Resident #1 was not wearing abdominal binder. The surveyor was unsuccessful in attempt to interview Resident #1 due to symptoms related to Dementia (intermittent confusion). Observation and interview with CNA T, on 03/25/2024, at 3:45pm, revealed CNA T positioned Resident #1 to aid in the surveyor's observation of Resident #1's abdominal gastrostomy tube site. Observation revealed Resident #1 was lying flat on her designated bed and was not wearing abdominal binder. Resident #1's abdominal gastrostomy tube site was not clean. There was a visibly soiled dressing, with dark red hanging below the gastrostomy tube site. Abdominal gastrostomy tube site was cover with dark red substance. Resident #1's gastrostomy tube contained dark red substance. Resident #1 was tensed and expressed that there was pain at the gastrostomy tube site. CNA T stated that the Resident often complained that there was pain at the gastrostomy tube site; and Resident #1 was often seen pulling the gastrostomy tube. CNA T stated that he had no knowledge of abdominal binder that was ordered for Resident #1. During observation the surveyor observed that there was signage post on the wall and the head of the resident bed reading resident is to remain in a 45-degree position. CNA T stated that he was aware of the sign but was not sure why the sign was posted. CNA T stated that the resident head of bed was always flat when he worked. Interview on 03/25/2024, at 4:00pm with the DON and Administrator, the Administrator stated that they were aware of the physician's order to implement the abdominal binder. According to the Administrator, Resident #1 was not wearing the abdominal binder due to the facility not having the proper sized abdominal binder. The DON and Administrator did not disclose the date they were made aware of the improper fit; how they were able to determine the appropriate/best size for the resident; why the facility did not have the proper size; and why the proper sized abdominal binder had not been implemented. The Administrator stated that the physician should have been notified that the order was not implemented and did not disclose why the physician was not notified. Interview on 03/25/2024 at 4:45pm with LVN V, LVN V stated that she had worked at the facility for three months. LVN V stated that she provided care for Resident #1 often since employed with the facility. LVN V stated that she was not aware that Resident #1 had an order to wear an abdominal binder. The surveyor asked LVN V how she was made aware of all orders for any given resident she worked with. She stated that the information was usually communicated during shift ending handoff report. LVN V confirmed that she had access to the clinical record including all active order for resident she was assigned to provide care to. LVN V stated that she did not routinely check the resident order each shift. LVN V stated that Resident #1 often complained of pain at the gastrostomy tube site and the resident was often seen pull on the G-tube. LVN V stated that she had noticed complications with the G-Tube and G-tube site. LVN V that she had not notified the physician of complications related to the G-Tube and site. The surveyor asked LVN V if she had knowledge related to why a resident would be ordered an abdominal binder. LVN V stated that the abdominal binder would usually prevent possible complication with the G-tube. LVN V stated that she noticed that the dressing had not been changed. She stated that the dressing containing the dark red substance appeared to be the dressing from when she cleaned the gastrostomy tube site three days ago, on Friday, 03/22/2024 as the dressing was dated for Friday, 03/22/2024 and not new dress had been applied. LVN V stated that Resident #1's gastrostomy tube site was to be cleaned daily and a clean dressing should be applied. LVN V stated that when orders were missed it could place residents at risk for medical neglect. LVN V stated that by missing the order for the abdominal binder it placed Resident #1 at risk for complications with the G-tube. Interview on 03/26/2024 at 9:45am with RN J, who state that she had worked with Resident # 1 since January/2024. RN J stated that Resident #1 often complained of pain at the gastrostomy tube site and the resident was often redirected from pulling on the G-tube. RN J stated that she had often experienced complications with the G-Tube when administrating medication via the G-Tube. RN J stated that she had not notified the physician of the complications with the G-Tube. RN J stated that she was not aware that Resident #1 had an order to for an abdominal binder prior to the start of her shift on 03/26/2024. RN J was not able to explain how the order was missed. RN J stated that she usually reviewed and confirmed orders in the electronic clinical record for all resident she was assigned to work with each shift. RN J stated that she was made aware at the start of her shift during handoff report that the resident was sent out to the hospital related to complications of the G- tube and G-tube site. The surveyor asked RN J if she had knowledge related to why a resident would be ordered an abdominal binder. RN J stated that an abdominal binder is to protect the G-tube and G- Tube site. RN J stated that she was informed that the resident was provided an abdominal binder that was placed on the resident at the hospital during the hospital visit on 03/15/2024. RN J stated that she had not previously seen the resident wearing an abdominal binder. The surveyor asked what could happen to a resident by not implementing physician orders. RN J stated that Resident #1 could possibly have complications or dislodge her G- Tube. Record review on 03/26/2024 of Resident #1 clinical record, nurse progress note revealed that Resident #1 was sent out to the hospital for G-Tube replacement on 03/25/2024 at 6:20pm. Progress note 03/25/2024 at 11:19 revealed that Resident # 1 was discharged from the hospital with discharge instructions to follow up with gastroenterology specialty service for replacement of G tube. The surveyor was unable to interview the assigned nurse working the night shift (11pm - 6am) who received the Resident # 1 upon return from the hospital. Observation and interview of Resident #1's medication administration pass performed by LVN V on 3/26/2024 at 5:45pm revealed LVN V explained to Resident #1 that she was going to administer medication with the standby assistance of CNA T. LVN V prepared Resident #1's medications by crushing them and mixing them in water to dissolve them. LVN V went to the bedside without a stethoscope and there was no stethoscope at the resident's bedside. LVN V removed an enteral feeding and irrigation syringe from an opened package, not dated, at the bedside. LVN V removed the plunger from the syringe, preceded and did not aspirate gastric content from the g-tube. LVN V did not check Resident #1's g-tube for placement by auscultating (listening with a stethoscope) for bowel sounds, visualizing the site to ensure the tube had not become dislodged and or was not infected or compromised in any way. LVN V proceeded by plunger pushing a full 60 ml syringe of water into Resident #1's g-tube. Resident observed guarding her abdomen and yelled it hurt, stop. Resident #1's bed was flat, and the head of the bed was not elevated. The surveyor stopped LVN V and asked her if that was the technique, she normally used to check to assess a resident's g-tube placement. LVN V stated, Yes, if it flushes then it is good to use. When asked if that was the way she had been trained to check for g-tube placement, she said she had only worked at the facility for three months. LVN V stated that she had been trained. LVN V tried to resume the medication administration and was stopped again by the surveyor when LVN V aspirated the medication out of the cup she had used to crush and mix Resident #1's medication with water and began to plunger push the medication with force into Resident #1's g-tube as if giving an injection. When asked to stop and asked if that was how she was trained to administer g-tube medications, LVN V confirmed that was the way she was trained. LVN V stated that she always pushed Resident #1's medications when administering via g-tube. LVN V stated that she knew how to administer g-tube medications to gravity. She then stated that in the past when she attempted to administer Resident #1 medications to gravity, she often experienced complications. LVN V stated that she never reported complications related to the g-tube. LVN V did not disclosed why she did not notify the physician of complications. The surveyor stopped the medication administration observation and requested the DON. LVN V plunger push the medication with force instead of administering medications to gravity. LVN V did not follow physician orders to flush feeding tube with 30ml(cc) of water before and after administration of medication pass. Interview on 03/26/2024, at 6:00pm with DON, Administrator, and Corporate Regional Nurse, the DON confirmed that nursing staff had been trained on medication administration via g-tube and managing the care of Resident's with G-Tubes. Interview on 03/26/2024, at 8:00pm with the facility Physician, the Physician stated that the abdominal binder that was ordered and indicated because Resident #1 continued to attempt to pull out g-tube. The Physician stated that he was not notified that the facility had not implemented the abdominal binder prior to 03/26/2024. The Physician confirmed that the order was a current and active order to prevent complications of the g-tube and comprise to the g-tube site. The Physician confirmed that he should have been notified with related to failure to implement the abdominal binder and any complication related to the G-tube and G-Tube site. Interview on 03/27/2024, at 9:30am with the DON, the surveyor asked what the expectation for nursing staff was related to implementing physician orders. The DON stated that all nursing staff were expected to implement orders. The DON stated that when staff failed to implement orders the failure could have a negative impact and decline related to the resident's overall wellbeing. The facility policy related to implementing doctor's orders and management of G-Tubes was requested. The policy related to implementing doctor's orders, medication administration, and management of G-Tubes was requested at 9:30am on 03/37/2024. Proof of in-services and staff training for medication administration. The facility failed to provide requested information as of 03/27/2024 at 5:00pm. Interview on 03/29/24 at 11:30am Central Supply Staff A stated that she started working at the facility in January of 2024. Central Supply Staff A stated that she was made aware on 01/11/2024 that Resident #1 had an order for an abdominal binder. Central Supply Staff A stated that she did not have access to place a supply order for an abdominal binder. She stated that the previous DON was responsible for placing the supply order. She stated she was aware that the order had been placed and that the binder had arrived because there was a big deal about the wrong size being delivered so she re-ordered it at that time in the correct size. She provided invoices for original delivery date of 12/26/23 and reorder on 2/20/24. She said she did not know the resident had been without the abdominal binder. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were notified on 03/27/2024 at 5:40pm. Plan of Removal - F580 Notice of Changes (submitted by facility/accepted at 03/28/2024 at 12:00pm) The facility failed to notify the resident's physician when the facility was unable to implement the physician order for abdominal binder. Immediate Action Resident #1 immediately assessed with no signs of distress noted. Abdominal binder obtained and placed on resident 3/25/24. LVN V immediately in serviced by DON and RNC related to g-tube care, checking placement, pushing and medication administration. Resident #1's orders were reviewed on 3/28/2024 and updated as needed to facilitate proper documentation. A gastroenterology follow-up appointment was set up by the facility for the next available day. The first available date was June 6, 2024. However, in consultation with the family and hospice, the g-tube will be removed as the resident is taking adequate PO intake/nutrition and the presence of the g-tube causes her undue distress. The facility reviewed the system for tube feeding and a review of the tube feeding policy was conducted by RNC to address any ambiguities that may have contributed to the incident. The facility revised a system including administrative nurses are reviewing residents that receive nutrition and/or medications via g-tube to assure that orders are followed, and new orders have been implemented as ordered during clinical meeting Monday - Friday. Ad HOC QAPI meeting will be completed with IDT consisting of Administrator, Regional Nurse Consultant, Administrative nurses and Medical Director 3/28/24 at 10 am. Facility interventions were implemented to remove immediate jeopardy: 1. Audit was completed by DON/RNC on 3/26/24 to identify any other residents with g- tubes in place to assure there were no complications related to g-tube care with no issues noted. 2. An audit was conducted by DON/RNC on 3/28/24 to identify other residents with changes of condition in the past 14 days to ensure MD was notified. 3. Education provided 3/26/24 to LVN V DON and RNC related to g-tube care, resident positioning, checking g-tube placement, pushing and medication administration. 4. Education initiated for licensed nursing staff by DON/Designee related to g-tube care, resident positioning, checking placement, pushing and medication administration and steps to take when g-tube is not functioning properly. On 3/28/2024, an in-service with all licensed nursing staff was initiated by RNC to reinforce the importance of maintaining proper positioning with residents receiving feeding by tube feeding and proper placement of abdominal binders. 5. Education was initiated on 3/28/2024 on notification of MD when resident refuses treatment, when a prescribed treatment is not available, or when a full amount of a medication is unable to be administered. This includes g-tube medication administration and site care. 6. Facility will be in compliance 3/28/24 by 1 PM *Education to be completed with all licensed nursing staff working 3/28/2024. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. State Surveyor Monitored the plan of removal as follows: Interview on 03/28/2024 at 12:13 with RN K (Day shift), RN K stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. RN K was able to verbalize knowledge and understanding congruent with facility G- Tube policy. Interview on 03/28/2024 at 12:42 with RN J (Day shift), RN J stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. RN J was able to verbalize knowledge related to G-Tube policy. Interview on 03/28/2024 at 6:00pm with, LVN V (2-10 shift), LVN V stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. LVN V was able to verbalize knowledge of positioning and administering medications via G-Tube. LVN V was also able to verbalize knowledge related checking placement of a G-Tube, pushing and medication administration, the importance to of an abdominal binder, and the process for notifying the physician and follow up related to change in resident status and inability to implement a physician's orders. Interview on 03/28/2024 at 6:15 with CNA T (2-10pm shift), CNA T stated that training was provided on 03/27/2024 and 03/28/2024 on how to position a resident with and G-Tube. Interview on 03/28/2024 at 6:35pm with MA M (2-10pm shift), MA M stated that training was provided on 03/27/2024 on how to position a resident with and G-Tube. MA was able to verbalize her knowledge related positioning Resident's with G-Tubes. Interview on 03/29/24 at10:00am CNA J stated she had been trained that if they needed any supplies or supplies were missing, she would let her charge nurse and central supply know. She stated that the facility had been trained on how to make sure the residents with g-tubes were not left flat and that the head of the bed was up to at least 30-45 degrees. She said she had been trained to report any behaviors or changes in resident to charge nurse. She said they did not have access to supplies like abdominal binders so she would have to check with the charge nurse or central supply but if something got soiled or needed to be cleaned or replaced, she would report it to charge nurse. Interview on 03/29/24 at10:16 AM RN J, RN J stated she was recently in-serviced on G-tubes including medication administration processes including flushing, checking placement and medications administered to gravity never pushing. She said she would report any changes in the resident's condition including G-tube function and site to the medical doctor as well as the nurse practitioner. She stated that if a resident refused care, she would always document but leave and try again and if unsuccessful during follow up attempts and would notify the medical doctor and nurse practitioner. She stated that night shift changed g-tube site dressings daily and that she checked her sites underneath the dressings on day shift when she came on-shift. Interview on 03/29/24 at 10:19am RN K stated that she was retrained on G-tube med pass and had been trained upon hire. She stated that if a resident refused care to go away, let them calm down and come back and try again later, if still unsuccessful, or time sensitive, she would notify the medical doctor and nurse practitioner right away. She stated that a g-tube resident should never be left lying flat and that she did sometimes work 300 halls but was not aware Resident #1 had an abdominal binder ordered. She stated that if something was unavailable, she would let medical doctor know so order could be validated, changed, or held. Interview on 03/29/24 at 10:25am RN L stated she had recently been trained on G-tubes, abdominal binder. She said that G- tubes in-service was regarding medication administration and positioning of the resident head elevated at least 30 degrees. She stated that medications were to be administered to gravity and no medications should be push via the G- Tube, as well as, checking placement and site and notifying physician of all changes including if an ordered intervention or medication is not available. She stated that refusals of medications or ordered interventions, therapies were also to be reported to physician and practitioner. She stated she would document accordingly in the resident's clinical record. Interview on 03/29/24 at 10:34am MA M stated she had recently been trained to ensure any residents with G-tubes were not left flat after ADL care and that the head of the bed was elevated to at least 30 degrees. She stated that if anything was different, changed, or abnormal for the resident she would report to her charge nurse. Interview on 03/29/24 at 10:35am MA D stated he had worked at the facility since 2021. He stated he had been trained upon hire but then recently trained on g-tubes and making sure residents with g-tubes are not left flat and have their heads raised to at least 30 degrees to prevent the resident from aspirating. He said that if anything was beeping or leaking or looked abnormal for any resident, he would immediately report it to the charge nurse. MA D stated that it is not in in scope to administer any medications via g-tubes. He stated that if he was working as an aide and he took anything off the resident like a binder during a shower or bath and took it to laundry, he would ensure it was placed back with or on the resident once cleaned, and if not report it to charge nurse so they know it's off. Interview on 03/29/24 at 10:54am wound care LVN T stated she had recently been trained on G-tubes including medication administration, and only administering via gravity and not pushing medications via G- Tube. She stated that in-service included how to check placement, flushing G- Tube, resident positioning, and if there are any issues with G-Tube how to notify the medical doctor, she stated staff was trained to call medical doctor or nurse practitioner for any changes/refusals of treatment, and document action in the resident clinical record. Interview on 03/29/24 at 11:30am Central Supply Staff A stated that she started working at the facility in January of 2024. She stated she had a recent in-service on G-tube feedings. She stated that residents with g- tubes should be left at a 30-45-degree angle. The surveyor team was able verify that facility implemented the following to remove the immediacy: The facility provided an audit list of residents with G-Tube placement. The physician's order was verified for identified the residents. No additional change condition identified for residents listed. In-service/training records for licensed nurses by regarding the proper care and management of tube feeding residents, including proper procedure for checking g-tube placement, administration techniques, and required actions/documentation when interventions are refused was verified by the surveyor team. Education/training record for LVN V related to g-tube care, resident positioning, checking g-tube placement, and medication administration was verified by the surveyor team. In-service/training records for implementing measures of monitoring, documenting, and reporting G-tube complications, provided care and management to G-Tube was verified by the surveyor team. In-service/training records for importance of maintaining proper positioning with residents receiving feeding by tube feeding and proper placement of abdominal binders provided was verified by the surveyor team. Record of those in attendance for QAPI meeting on 3/28/24 at 10:00am was provided and verified by the surveyor teams. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were informed on 03/27/2024 at 5:40pm. The IJ was lowered on 03/29/23 at 1:33pm, the facility remained out of compliance at a scope of pattern and a severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure one of four residents (Resident #1) who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, in that: The facility failed to implement the physician's order for an abdominal binder indicated to prevent complications of gastrostomy tube. The facility failure resulted in Resident #1 requiring discharge to the hospital for G-Tube replacement. LVN V failed to use the facility's identified proper technique and safety precautions for Resident # 1 for administering medications via G- Tube. LVN V's failure resulted in LVN V administering medications by plunger pushing the medications into Resident #1 gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms associated G-Tube blockage and Aspiration (occurs when liquid or food enters the lungs). The facility failed to implement physician's order to provide gastrostomy tube site care to Resident #1 G-Tube site. The facility failure placed Resident #1 at immediate risk the development of infection. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were informed on 03/27/2024 at 5:40pm. The IJ was lowered on 03/29/23 at 1:33pm, the facility remained out of compliance at a scope of isolated and a severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The identified failures have the potential to cause significant complications, including infections, aspiration, hospitalization s, or death, in residents with gastrostomy tubes. Findings included: Record review of Resident #1's face sheet dated 03/25/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old female. Resident #1 had a diagnosis of Gastrostomy Status (the creation of an artificial external opening into the stomach for nutritional support or gastric decompression via a G- Tube) and Gastro-Esophageal Reflux Disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus) dated 08/26/2023. Record review of clinical record, Resident #1's Care Plan revealed that Resident #1 require to have an abdominal feeding tube. Care Plan Goal: Resident was to remain free of side effect of complication Resident insertion site will be free of sign and symptoms of infection. Interventions Task: Check tube placement and gastric contents/residual volume per facility protocol and record (policy). Monitor/document/ report tube dysfunction or malfunction, abdominal pain, and infection at the tube site provide local care to G-Tube site as ordered administer medication as ordered. Record review of clinical record, Resident #1's MDS revealed that Resident #1 required abdominal feeding tube. Record review of Resident #1's physician's order summary report revealed the following order: every shift for flush feeding tube with 30ml(cc) of water before and after administration of medication pass. clean and change dressing one time a day. Apply abdominal binder, order dated as of 12/07/2023. Record review of clinical record, Resident #1's MAR/TAR revealed no documentation that the physician order for abdominal binder had been followed and implemented from 12/07/2023 thru 03/25/2024. Record review of clinical record, Resident #1 progress notes revealed no documentation of G-tube complication such as dysfunction or malfunction and ongoing reported abdominal pain as of 03/25/2024. Observation made on 03/25/2024 at 10:30am revealed Resident #1 was not wearing abdominal binder. The surveyor was unsuccessful in attempt to interview Resident #1 due to symptoms related to Dementia (intermittent confusion). Observation and interview with CNA T, on 03/25/2024, at 3:45pm, revealed CNA T positioned Resident #1 to aid in the surveyor's observation of Resident #1's abdominal gastrostomy tube site. Observation revealed Resident #1 was lying flat on her designated bed and was not wearing abdominal binder. Resident #1's abdominal gastrostomy tube site was not clean. There was a visibly soiled dressing, with dark red hanging below the gastrostomy tube site. Abdominal gastrostomy tube site was cover with dark red substance. Resident #1's gastrostomy tube contained dark red substance. Resident #1 was tensed and expressed that there was pain at the gastrostomy tube site. CNA T stated that the Resident often complained that there was pain at the gastrostomy tube site; and Resident #1 was often seen pulling the gastrostomy tube. CNA T stated that he had no knowledge of abdominal binder that was ordered for Resident #1. During observation the surveyor observed that there was signage post on the wall and the head of the resident bed reading resident is to remain in a 45-degree position. CNA T stated that he was aware of the sign but was not sure why the sign was posted. CNA T stated that the resident head of bed was always flat when he worked. Interview on 03/25/2024, at 4:00pm with the DON and Administrator, the Administrator stated that they were aware of the physician's order to implement the abdominal binder. According to the Administrator, Resident #1 was not wearing the abdominal binder due to the facility not having the proper sized abdominal binder. The DON and Administrator did not disclose the date they were made aware of the improper fit; how they were able to determine the appropriate/best size for the resident; why the facility did not have the proper size; and why the proper sized abdominal binder had not been implemented. The Administrator stated that the physician should have been notified that the order was not implemented and did not disclose why the physician was not notified. Interview on 03/25/2024 at 4:45pm with LVN V, LVN V stated that she had worked at the facility for three months. LVN V stated that she provided care for Resident #1 often since employed with the facility. LVN V stated that she was not aware that Resident #1 had an order to wear an abdominal binder. The surveyor asked LVN V how she was made aware of all orders for any given resident she worked with. She stated that the information was usually communicated during shift ending handoff report. LVN V confirmed that she had access to the clinical record including all active order for resident she was assigned to provide care to. LVN V stated that she did not routinely check the resident order each shift. LVN V stated that Resident #1 often complained of pain at the gastrostomy tube site and the resident was often seen pull on the G-tube. LVN V stated that she had noticed complications with the G-Tube and G-tube site. LVN V that she had not notified the physician of complications related to the G-Tube and site. The surveyor asked LVN V if she had knowledge related to why a resident would be ordered an abdominal binder. LVN V stated that the abdominal binder would usually prevent possible complication with the G-tube. LVN V stated that she noticed that the dressing had not been changed. She stated that the dressing containing the dark red substance appeared to be the dressing from when she cleaned the gastrostomy tube site three days ago, on Friday, 03/22/2024 as the dressing was dated for Friday, 03/22/2024 and not new dress had been applied. LVN V stated that Resident #1's gastrostomy tube site was to be cleaned daily and a clean dressing should be applied. LVN V stated that when orders were missed it could place residents at risk for medical neglect. LVN V stated that by missing the order for the abdominal binder it placed Resident #1 at risk for complications with the G-tube. Interview on 03/26/2024 at 9:45am with RN J, who state that she had worked with Resident # 1 since January/2024. RN J stated that Resident #1 often complained of pain at the gastrostomy tube site and the resident was often redirected from pulling on the G-tube. RN J stated that she had often experienced complications with the G-Tube when administrating medication via the G-Tube. RN J stated that she had not notified the physician of the complications with the G-Tube. RN J stated that she was not aware that Resident #1 had an order to for an abdominal binder prior to the start of her shift on 03/26/2024. RN J was not able to explain how the order was missed. RN J stated that she usually reviewed and confirmed orders in the electronic clinical record for all resident she was assigned to work with each shift. RN J stated that she was made aware at the start of her shift during handoff report that the resident was sent out to the hospital related to complications of the G- tube and G-tube site. The surveyor asked RN J if she had knowledge related to why a resident would be ordered an abdominal binder. RN J stated that an abdominal binder is to protect the G-tube and G- Tube site. RN J stated that she was informed that the resident was provided an abdominal binder that was placed on the resident at the hospital during the hospital visit on 03/15/2024. RN J stated that she had not previously seen the resident wearing an abdominal binder. The surveyor asked what could happen to a resident by not implementing physician orders. RN J stated that Resident #1 could possibly have complications or dislodge her G- Tube. Record review on 03/26/2024 of Resident #1 clinical record, nurse progress note revealed that Resident #1 was sent out to the hospital for G-Tube replacement on 03/25/2024 at 6:20pm. Progress note 03/25/2024 at 11:19 revealed that Resident # 1 was discharged from the hospital with discharge instructions to follow up with gastroenterology specialty service for replacement of G tube. The surveyor was unable to interview the assigned nurse working the night shift (11pm - 6am) who received the Resident # 1 upon return from the hospital. Observation and interview of Resident #1's medication administration pass performed by LVN V on 3/26/2024 at 5:45pm revealed LVN V explained to Resident #1 that she was going to administer medication with the standby assistance of CNA T. LVN V prepared Resident #1's medications by crushing them and mixing them in water to dissolve them. LVN V went to the bedside without a stethoscope and there was no stethoscope at the resident's bedside. LVN V removed an enteral feeding and irrigation syringe from an opened package, not dated, at the bedside. LVN V removed the plunger from the syringe, preceded and did not aspirate gastric content from the g-tube. LVN V did not check Resident #1's g-tube for placement by auscultating (listening with a stethoscope) for bowel sounds, visualizing the site to ensure the tube had not become dislodged and or was not infected or compromised in any way. LVN V proceeded by plunger pushing a full 60 ml syringe of water into Resident #1's g-tube. Resident observed guarding her abdomen and yelled it hurt, stop. Resident #1's bed was flat, and the head of the bed was not elevated. The surveyor stopped LVN V and asked her if that was the technique, she normally used to check to assess a resident's g-tube placement. LVN V stated, Yes, if it flushes then it is good to use. When asked if that was the way she had been trained to check for g-tube placement, she said she had only worked at the facility for three months. LVN V stated that she had been trained. LVN V tried to resume the medication administration and was stopped again by the surveyor when LVN V aspirated the medication out of the cup she had used to crush and mix Resident #1's medication with water and began to plunger push the medication with force into Resident #1's g-tube as if giving an injection. When asked to stop and asked if that was how she was trained to administer g-tube medications, LVN V confirmed that was the way she was trained. LVN V stated that she always pushed Resident #1's medications when administering via g-tube. LVN V stated that she knew how to administer g-tube medications to gravity. She then stated that in the past when she attempted to administer Resident #1 medications to gravity, she often experienced complications. LVN V stated that she never reported complications related to the g-tube. LVN V did not disclosed why she did not notify the physician of complications. The surveyor stopped the medication administration observation and requested the DON. LVN V plunger push the medication with force instead of administering medications to gravity. LVN V did not follow physician orders to flush feeding tube with 30ml(cc) of water before and after administration of medication pass. Interview on 03/26/2024, at 6:00pm with DON, Administrator, and Corporate Regional Nurse, the DON confirmed that nursing staff had been trained on medication administration via g-tube and managing the care of Resident's with G-Tubes. Interview on 03/26/2024, at 8:00pm with the facility Physician, the Physician stated that the abdominal binder that was ordered and indicated because Resident #1 continued to attempt to pull out g-tube. The Physician stated that he was not notified that the facility had not implemented the abdominal binder prior to 03/26/2024. The Physician confirmed that the order was a current and active order to prevent complications of the g-tube and comprise to the g-tube site. The Physician confirmed that he should have been notified with related to failure to implement the abdominal binder and any complication related to the G-tube and G-Tube site. Interview on 03/27/2024, at 9:30am with the DON, the surveyor asked what the expectation for nursing staff was related to implementing physician orders. The DON stated that all nursing staff were expected to implement orders. The DON stated that when staff failed to implement orders the failure could have a negative impact and decline related to the resident's overall wellbeing. The facility policy related to implementing doctor's orders and management of G-Tubes was requested. The policy related to implementing doctor's orders, medication administration, and management of G-Tubes was requested at 9:30am on 03/37/2024. Proof of in-services and staff training for medication administration. The facility failed to provide requested information as of 03/27/2024 at 5:00pm. Interview on 03/29/24 at 11:30am Central Supply Staff A stated that she started working at the facility in January of 2024. Central Supply Staff A stated that she was made aware on 01/11/2024 that Resident #1 had an order for an abdominal binder. Central Supply Staff A stated that she did not have access to place a supply order for an abdominal binder. She stated that the previous DON was responsible for placing the supply order. She stated she was aware that the order had been placed and that the binder had arrived because there was a big deal about the wrong size being delivered so she re-ordered it at that time in the correct size. She provided invoices for original delivery date of 12/26/23 and reorder on 2/20/24. She said she did not know the resident had been without the abdominal binder. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were notified on 03/27/2024 at 5:40pm. Plan of Removal - F693 Tube Feeding Management (submitted by facility/accepted at 03/28/2024 at 12:00pm) PLAN OF REMOVAL: F693 Tube Feeding Management The facility failed to implement the physician's order for abdominal binder, and medication administration through the gastrostomy was not performed in accordance with facility policy and procedure. Immediate Action Resident #1: An abdominal binder was placed on 3/25/2024 per physician's orders. LVN V immediately in serviced by DON and RNC related to g-tube care, checking placement, pushing and medication administration. The resident was immediately assessed by DON for adverse effects from gastrostomy feeding on 3/26/24. The resident was offered site care, and the refusal of care was documented. An incident report was completed related to the incorrect feeding procedure, missed dose of lactulose, and missed documentation of gastrostomy tube site care refusal. Resident #1's orders were reviewed on 3/28/2024 and updated as needed to facilitate proper documentation. A gastroenterology follow-up appointment was set up for June 6, 2024. However, in consultation with the family and hospice, the g-tube will be removed as the resident is taking adequate PO intake/nutrition and the presence of the g-tube causes her undue distress. The facility reviewed the system for tube feeding and a review of the tube feeding policy was conducted by RNC to address any ambiguities that may have contributed to the incident. The facility revised a system including administrative nurses are reviewing residents that receive nutrition and/or medications via g-tube to assure that proper procedures are followed during clinical meeting Monday - Friday. Ad HOC QAPI meeting will be completed with IDT consisting of Administrator, Regional Nurse Consultant, Administrative nurses and Medical Director 3/28/24 at 10 am. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: 1. An audit was completed by RNC on 3/27/2024 of all residents receiving tube feedings to validate that physician's orders were implemented and that the g-tube and g-tube site were clean and functioning. No further issues were identified. 2. On 3/26/2024, an in-service was initiated with all licensed nurses by DON regarding the proper care and management of tube feeding residents, including proper procedure for checking g-tube placement, administration techniques, and required actions/documentation when interventions are refused. 3. 3/28/2024, a review of the Point Click Care enteral feeding batch orders was conducted by RNC, and orders were reviewed to validate they prompt the nurse to document each shift that they were implemented or refused. 4. On 3/28/2024, an in-service with licensed nurses was initiated by RNC to reinforce the importance of maintaining proper positioning with residents receiving feeding by tube feeding and proper placement of abdominal binders. 5. On 3/28/2024, a review of the facility in-service schedule was conducted by RNC and updated to implement quarterly in-services regarding the care of residents receiving enteral feeding. 6. Facility will be in compliance by 3/28/2024 at 1pm. *Education to be completed with all nurses working 3/28/2024. Staff who did not receive this training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. State Surveyor Monitored the plan of removal as follows: Interview on 03/28/2024 at 12:13 with RN K (Day shift), RN K stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. RN K was able to verbalize knowledge and understanding congruent with facility G- Tube policy. Interview on 03/28/2024 at 12:42 with RN J (Day shift), RN J stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. RN J was able to verbalize knowledge related to G-Tube policy. Interview on 03/28/2024 at 6:00pm with, LVN V (2-10 shift), LVN V stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. LVN V was able to verbalize knowledge of positioning and administering medications via G-Tube. LVN V was also able to verbalize knowledge related checking placement of a G-Tube, and medication administration, the importance to of an abdominal binder, and the process for notifying the physician and follow up related to change in resident status and inability to implement a physician's orders. Interview on 03/28/2024 at 6:15 with CNA T (2-10pm shift), CNA T stated that training was provided on 03/27/2024 and 03/28/2024 on how to position a resident with and G-Tube. Interview on 03/28/2024 at 6:35pm with MA M (2-10pm shift), MA M stated that training was provided on 03/27/2024 on how to position a resident with and G-Tube. MA was able to verbalize her knowledge related positioning Resident's with G-Tubes. Interview on 03/29/24 at10:00am CNA J stated she had been stated that she had been trained if they needed any supplies or supplies were missing, she would let her charge nurse and central supply know. She stated that the facility had been trained on how to make sure the residents with g-tubes were not left flat and that the head of the bed was up to at least 30-45 degrees. She said she had been trained to report any behaviors or changes in resident to charge nurse. She said they did not have access to supplies like abdominal binders so she would have to check with the charge nurse or central supply but if something got soiled or needed to be cleaned or replaced, she would report it to charge nurse. Interview on 03/29/24 at10:16 AM RN J , RN J stated she was recently in-serviced on G-tubes including medication administration processes including flushing, checking placement and medications administered to gravity never pushing. She said she would report any changes in the resident's condition including G-tube function and site to the medical doctor as well as the nurse practitioner. She stated that if a resident refused care, she would always document but leave and try again and if unsuccessful during follow up attempts and would notify the medical doctor and nurse practitioner. She stated that night shift changed g-tube site dressings daily and that she checked her sites underneath the dressings on day shift when she came on-shift. Interview on 03/29/24 at 10:19am RN K stated that she was retrained on G-tube med pass and had been trained upon hire. She stated that if a resident refused care to go away, let them calm down and come back and try again later, if still unsuccessful, or time sensitive, she would notify the medical doctor and nurse practitioner right away. She stated that a g-tube resident should never be left lying flat and that she did sometimes work 300 halls but was not aware Resident #1 had an abdominal binder ordered. She stated that if something was unavailable, she would let medical doctor know so order could be validated, changed, or held. Interview on 03/29/24 at 10:25am RN L stated she had recently been trained on G-tubes, abdominal binder. She said that G- tubes in-service was regarding medication administration and positioning of the resident head elevated at least 30 degrees. She stated that medications were to be administered to gravity and no medications should be push via the G- Tube, as well as, checking placement and site and notifying physician of all changes including if an ordered intervention or medication is not available. She stated that refusals of medications or ordered interventions, therapies were also to be reported to physician and practitioner. She stated she would document accordingly in the resident's clinical record. Interview on 03/29/24 at 10:34am MA M stated she had recently been trained to ensure any residents with G-tubes were not left flat after ADL care and that the head of the bed was elevated to at least 30 degrees. She stated that if anything was different, changed, or abnormal for the resident she would report to her charge nurse. Interview on 03/29/24 at 10:35am MA D stated he had worked at the facility since 2021. He stated he had been trained upon hire but then recently trained on g-tubes and making sure residents with g-tubes are not left flat and have their heads raised to at least 30 degrees to prevent the resident from aspirating. He said that if anything was beeping or leaking or looked abnormal for any resident, he would immediately report it to the charge nurse. MA D stated that it is not in in scope to administer any medications via g-tubes. He stated that if he was working as an aide and he took anything off the resident like a binder during a shower or bath and took it to laundry, he would ensure it was placed back with or on the resident once cleaned, and if not report it to charge nurse so they know it's off. Interview on 03/29/24 at 10:54am wound care LVN T stated she had recently been trained on G-tubes including medication administration, and only administering via gravity and not pushing medications via G- Tube. She stated that in-service included how to check placement, flushing G- Tube, resident positioning, and if there are any issues with G-Tube how to notify the medical doctor, she stated staff was trained to call medical doctor or nurse practitioner for any changes/refusals of treatment, and document action in the resident clinical record. Interview on 03/29/24 at 11:30am Central Supply Staff A stated that she started working at the facility in January of 2024. She stated she had a recent in-service on G-tube feedings. She stated that residents with g- tubes should be left at a 30-45-degree angle. The surveyor team was able verify that facility implemented the following to remove the immediacy: The facility provided an audit list of residents with G-Tube placement. The physician's order was verified for identified the residents. In-service/training records for licensed nurses by regarding the proper care and management of tube feeding residents, including proper procedure for checking g-tube placement, administration techniques, and required actions/documentation when interventions are refused was verified Record review of MAR/TAR and nursing progress note revealed that nursing staff have implemented measures of monitoring, documenting, and reporting G-tube complications, provided care and management to G-Tube. In-service/training records for importance of maintaining proper positioning with residents receiving feeding by tube feeding and proper placement of abdominal binders provided was verified by the surveyor team. Record of those in attendance for QAPI meeting on 3/28/24 at 10:00am was provided and verified by the surveyor teams. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were informed on 03/27/2024 at 5:40pm. The IJ was lowered on 03/29/23 at 1:33pm, the facility remained out of compliance at a scope of isolated and a severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (Resident # 1) of 7 residents reviewed for respiratory care. The facility failed to ensure Resident #1 was provided oxygen during transport to doctors appointment in which Resident #1 arrived to appointment with O2 level at 73%, had difficulty breathing adn required O2. An IJ was identified on 3/7/2024. The IJ template was provided to the facility on [DATE] at 4:20 pm. While the IJ was removed on 3/8/2024, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who received oxygen therapy at risk of respiratory complications and/or death. The findings included: Record review of Resident # 1's Admission Records, dated 2/12/2022, revealed a [AGE] year-old male who was admitted on [DATE]. Resident's diagnoses included Chronic Obstructive Pulmonary Disease (obstructed airflow from the lungs), Atrial Fibrillation (an irregular rapid heart rate that causes poor blood flow), Atherosclerotic Heart Disease of Native Coronary Artery without Angina(Coronary artery disease starts when fats, cholesterols and other substances collect on the inner walls of the heart arteries), Diabetes Mellitus (A group of diseases that result in too much sugar in the blood), and Hypertensive Heart Disease with Heart Failure (Hypertensive heart disease can lead to either diastolic heart failure, systolic failure, or a combination of the two). Record review of Resident #1's care plan, dated 2/119/2024, revealed Resident # 1 had COPD, Hypoxic (an absence of enough oxygen), Hypercapnic(high levels of carbon dioxide in the blood) , Respiratory Failure(blood does not have oxygen or has to much carbon dioxide), Pulmonary Hypertension(high blood pressure that affects arteries), and Pulmonary Edema ( excess fluid in the lungs). Goal: The resident would be free of s/sx of complications of cardiac problems through the review date. The resident will display optimal breathing patterns daily through the review date. Interventions: aerosol or bronchodilators as ordered, give cardiac medication as ordered by physician, monitoring for difficulty breathing (Dyspnea) on exertion, and monitoring for s/sx for acute respiratory insufficiency. Record review of Resident # 1's physician orders, dated 1/9/2024, reflected in part oxygen at 5L/min via nasal cannula continuous. Directions: every shift for Dyspnea, start date 1/9/2024 . Record review of Resident # 1's O2 sat summary, dated 2/21/2024- 2/23/2024, reflected in part: Date/Time Value Method 2/23/2024 at 8:19 am 97% Room Air 2/22/2024 at 10:58 pm 97% Oxygen via Nasal Canula 2/22/2024 at 8:29 pm 95% Oxygen via Nasal Canula 2/22/2024 at 9:50 am 93% Oxygen via Nasal Canula 2/21/2024 at 11:16 pm 94% Oxygen via Nasal Canula 2/21/2024 at 10:44 am 95% Oxygen via Nasal Canula 2/21/2024 at 6:30 am 94% Room Air 2/21/2024 at 00:15 am 95% Oxygen via Nasal Canula In a telephone interview with the Clinic Nurse on 2/23/2024 at 11:00 am she reported that Resident #1 had an office visit on 2/22/2024. She reported that Resident # 1 arrived without a portable oxygen tank. She reported that Resident #1 oxygen level was at 73% and Resident # 1 stated he had shortness of breath but was not under respiratory distress. She reported that Resident # 1 was administered 4L O2 supply and Resident # 1 breathing improved. She stated that Resident # 1's oxygen saturation increased to 91-93%. She stated that Resident # 1 should have a portable oxygen tank. She stated that she contacted the Nursing Facility and she spoke with the ADON who confirmed that Resident # 1 was oxygen dependent. In an interview with Resident # 1 on 2/23/2024 at 12:10 pm he stated he was administered oxygen throughout the day 3 times a day. He stated that he was transported to a Pulmonary visit a on 2/22/2024. He stated was given oxygen earlier that day and when he left the facility he felt fine. He stated he walked from the waiting area to the examining room and was short of breath. He stated that he always had shortness of breath due to his COPD. He stated that the clinic nurse checked his oxygen, and it was low. He stated that the nurse at the clinic administered oxygen and he felt better. He stated that in the past when he left the facility, he was transported with a portable oxygen tank. In an interview with the ADON on 2/23/2024 at 2:40 pm she stated that Resident # 1 was transported to the clinic without a portable oxygen tank. She stated that Resident # 1 is on continuous oxygen and the portable oxygen tank should have been transported with Resident # 1. She stated that she was informed by the clinic nurse that when Resident # 1 arrived at the clinic his oxygen level was at 75%. The ADON stated that was Resident # 1's attending nurse LVN A) responsibility to make certain that he was transported with a portable oxygen tank. She stated if a residents oxygen level was 74%, he could have gone into respiratory failure. She stated it could have been fatal. In an interview with LVN A on 2/23/2024 at 2:59 pm she stated she was Resident # 1's nurse and she was not aware that Resident # 1 had left the facility. She stated she was aware the Resident # 1 had an appointment. She stated that the transporter asked her to print out paperwork for Resident # 1. She stated that she informed the transporter that she would print the paperwork for Resident # 1 once she finished assisting another resident. She stated that when she returned to the desk to retrieve the paperwork Resident # 1 was gone. She stated that she did not assess Resident # 1 prior to him being transported to his appointment. She stated that Resident # 1 is oxygen dependent, and he should have been transported with a portable oxygen tank. She stated that Resident # 1 was on continuous oxygen. She stated that the nurse is responsible for making certain the resident is transported with a portable oxygen tank. She stated that if a resident's oxygen level is low the resident could have gone into respiratory distress. In an interview with the Transporter, on 2/23/2024 at 3:32 pm he stated that LVN A was aware that Resident # 1 was being transported to a clinic visit. The Transporter stated that LVN A printed the admission paperwork for Resident # 1 and gave it to him. He stated that he met Resident # 1 in the hallway, and he assumed Resident # 1 was ready for transport. He stated that Resident # 1 was transported to the clinic visit without the portable oxygen tank. The Transporter stated that the nurse is responsible for making certain that residents have all needed items prior to being transported. He stated that he does not review the Resident's paperwork. He stated that LVN A gave him Resident # 1 paperwork and he transported Resident # 1 to his appointment. He stated that he is aware that Resident # 1 is on oxygen, however, he normally saw Resident # 1 off oxygen as Resident # 1 is a smoker. He stated that Resident # 1 did not have portable oxygen tank during transport. In an interview with the Administrator, on 2/23/2024 at 4:00 pm he stated that he was aware that Resident # 1 was on oxygen, however, he did not know if the oxygen was prn or continuous. He stated he was not aware that Resident # 1 left the facility without the portable oxygen tank. The Administrator stated that when a resident is transported from the facility the transporter meets with the nurse regarding the resident needs. The Regional Nurse and Administrator were notified on 3/7/2024 at 4:20 pm that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at this time and a plan of removal was requested The facility's Plan of Removal was accepted on 3/8/2024 at 1:41 pm and included: PLAN OF REMOVAL: F695 Name of facility: Cascades at Galveston Date: March 7, 2024 The facility failed to ensure Resident #1 was provided respiratory care consistent with professional standards of practice. Resident #1 was transported to an offsite physician's office and was not provided continuous oxygen as ordered by his physician. Immediate action: Resident #1 was immediately assessed ADON upon return to the facility from appointment on 2/22/24 and found to have an O2 sat of 97%. Since time of incident, resident's oxygen order was changed and only to be administered PRN based on his oxygen level. On 3/7/24 the facility IDT reviewed/revised the system for assuring that any resident that is to be on continuous oxygen has the oxygen in place prior to leaving the facility for any appointments where transportation is provided by the facility and created a plan of improvement to address changes including placing an additional transportation binder that identifies each resident that is on continuous oxygen. In addition, a blue alert sheet will be placed in front of the individual sign out sheet for resident that is on continuous oxygen that will alert anyone wishing to sign the resident out of the facility to Please see nurse prior to signing resident out on pass. Ad Hoc QAPI meeting completed with IDT, Regional Nurse Consultant, Administrator, Administrative Nurses, and Medical Director on 3/7/24 at 7 p.m. Policy for transportation reviewed and updated by IDT on 3/7/24 to address residents on continuous oxygen. Approved by medical director on 3/7/24. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: 1. A facility audit was conducted by Regional Nurse Consultant (RNC), on 3/7/24 to identify any resident currently ordered to be on continuous oxygen to determine if they had any appointments within the last 30 days that they went to without oxygen in place. None were identified. 2. RNC completed education to transportation tech on 3/7/24 related to determining if a resident requires continuous oxygen by utilizing the transportation binder at the nurse's station that lists all residents with orders for continuous oxygen, assuring that the resident has the oxygen in place prior to leaving facility and steps to take if issues arise. In addition, a blue alert sheet will be placed in front of the individual sign out sheet for resident that is on continuous oxygen that will alert anyone wishing to sign the resident out of the facility to Please see nurse prior to signing resident out on pass. 3. Education initiated by RNC/ADON to nursing staff related to determining if a resident requires continuous oxygen, assuring that the resident has the oxygen in place prior to leaving for any facility transported appointment. If a resident is being transferred by an outside transportation company or family member, a copy of the blue alert sheet will be attached to the resident face sheet indicating that they require continuous oxygen. *Education to be completed with all nursing staff working 3/8/2024. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. 4. Administrative nurse in-serviced 3/7/24 by RNC regarding assuring that any resident that is placed on continuous oxygen is placed in the binder and to check appointments daily in clinical meeting, updating the transport binder at the nurses station if needed, assuring that any resident that receives a new order for continuous oxygen is placed in the binder and an alert sheet is placed in the sign out book. Nursing staff and the transportation tech will have access to the transportation binder at the nurse's station. 5. Facility will be in compliance 3/8/24 by 1 PM Following the acceptance of the facility's Plan of Removal ( POR), the facility was monitored on 3/8/2024. Monitoring of the POR included: Record review of in-service that discussed all residents that are to be on continuous oxygen must have a portable tank sent with them any time they leave the facility for an appointment. If a resident refuses to wear oxygen that is ordered to be continuous, the MD and RP must be notified. Any resident that is to be on continuous oxygen will be additionally identified by the presence of a blue alert sheet in the transportation binder at the nurse's station, dated 3/7/2024, revealed 29 signatures and 4 phone in-services. The targeted audience: Nurses. Record review of in-service that discussed all residents that are to be on continuous oxygen must have a portable tank sent with them any time they leave the facility for an appointment. If a resident refuses to wear oxygen that is ordered to be continuous, the MD and RP must be notified. Any resident that is to be on continuous oxygen will be additionally identified by the presence of a blue alert sheet in the transportation binder at the nurse's station. Van driver is to verify if the resident being transported has a blue sheet indicating that they are to be on continuous oxygen. If a blue sheet is present the van driver should not leave the facility without the resident having a portable oxygen bottle. Any issues are to be reported to the DON/ADON prior to leaving the facility with the resident, dated 3/7/2024, revealed 1 signature. The targeted audience: Van Driver. Record review of in-service that discussed it is the responsibility of the nurse management team to review any appointment scheduled for the day to determine if any resident that currently has an order for continuous oxygen has a scheduled appointment for that day. If an appointment is scheduled, you must assure that the staff responsible for the resident's care and transportation are aware that the resident must have oxygen in place via portable O2 tank for the appointment, dated 3/2024, revealed 1 signature. The targeted audience: ADON. Record review of in-service that discussed if a resident is being transferred by an outside transportation company or family member, a copy of the blue alert sheet will be attached to the resident face sheet indicating that they require oxygen. In order to ensure that family members or other parties that are taking residents out on a pass are aware that they need to have oxygen, a blue sheet will be placed in front of the resident's individual sign out sheet indicating to Please see nurse prior to signing resident out on pass, dated 3/8/2024, revealed 17 signatures. Record review of Resident # 1's orders revealed 02 per nc@2-4 L/min PRN. Goal to maintain Sats at or above 90%. Check O2sat qshift. Use lowest level of oxygen required to achieve desired O2 saturation, start date 3/7/2024. During interviews on 3/8/2024, the following nurses were able to verbalize an understanding that all residents that are to be on continuous oxygen must have a portable oxygen tank sent with them any time they leave the facility: Nurse A, B, C, AND D; LVN B, C, D, AND E; and the Transporter. An Immediate Jeopardy (IJ) was identified on 3/7/2024 at 4:20 pm. While the IJ was removed on 3/8/2024 at 4:41 pm the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and records reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to follow physician orders for CR #1 who was weak, confused, and short of breath resulting in a O2 saturation at 90% and who passed away a little under 2 hours later. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who received oxygen therapy at risk of respiratory complications and/or death. The findings included: Record review of CR #1's Admission Record, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] and a discharge date of [DATE]. Resident's diagnoses included chronic obstructive pulmonary disease (obstructive airflow from the lungs) with acute exacerbation (sudden worsening of COPD symptoms), anxiety disorder, acute and chronic respiratory failure with hypoxia (condition where the lungs and the blood cannot exchange enough oxygen, causing low oxygen levels in the blood and tissues), and malignant neoplasm of unspecified kidney, except renal pelvis (cancer that affects the kidney, excluding the part that connects to the ureter). Record review of CR #1's care plan, undated, revealed CR #1 had COPD related to smoking. Goal: The resident would be free of s/sx of respiratory infections through the reviewed date. Interventions: aerosol or bronchodilators as ordered, monitoring for s/sx for acute respiratory insufficiency and infection, and oxygen as ordered, wean as able, check RA sats as ordered. Record review of CR #1's MDS assessment, dated [DATE], revealed Section C, C0100, BIMS was not completed. Further review revealed resident required one-person assist with mobility, transferring, and setup help with toileting. It also indicated that the resident was not on oxygen therapy. Record review of CR #1's physician orders, undated, reflected in part .O2 per nc at ,d+[DATE]L/min continuous. Check O2 sat qshift. Goal to maintain O2 sats >90%, start date [DATE] . Record review of CR #1's progress note, dated [DATE] at 10:51, read in part .Resident very weak, confused and SOB. Resident O2 @90% on 3L/min .Resident given prn dose morphine and Haldol. Resident visibly anxious. Resident continues to sit at the edge of her bed and then laying backwards, causing resident to lay in a perpendicular manner while at the same time being flat on her back. Throughout shift nursing staff and NOD continue to make sure residents head is raised and is not laying perpendicular in bed. Vitals O2 @90% on 3L/MIN, BP-,d+[DATE], Pulse-96, resp labored at 22. Resident continuously reminded to not sit on side of bed and to keep head elevated. Will continue to monitor. In a telephone interview on [DATE] at 1:17 p.m., Nurse C said CR #1 was found lying face down on the floor of her room on [DATE] by Nurse A. He said he was on a different hall performing blood sugar checks at the time of the incident. He said Nurse B called him and told him that CR #1 was found on the floor. He said when he entered CR #1's room, he saw her lying face down near the foot of her bed. He said she was unconscious, breathing, and there was a small pool of blood near her head. He said it appeared CR #1 had fallen onto the floor. He said Nurse A and him placed CR #1 in the recovery position [on her side]. He said he called CNA A and told her they needed her help. He said CNA A, Nurse A, and himself transferred CR #1 to her bed. He said once the resident was transferred back onto her bed, her O2 was placed back on her with continuous oxygen at 3L/min and the HOB was elevated. He said the resident was cleaned up and noted to have a laceration on the bridge of her nose. He said when the O2 was placed back on CR #1, she was still breathing at a low pace of 6 to 8 breaths per minute. He said he asked CR #1's roommate what happened, and he told him she got up onto her wheelchair and then faceplanted right away after getting onto her wheelchair. He said he called and notified the hospice nurse and the Administrator. He said the day before, Saturday, [DATE], CR #1 was lethargic, unable to open her eyes very much the entire day and would continuously sit on the side of her bed with her feet hanging over the side. He said CR #1 was educated on the importance of not sitting on the side of her bed, but resident was unable to retain the information. He said nursing staff made 5-minute rounds around the clock to ensure the resident was not lying flat on her back, or sideways in her bed, and/or her room floor. He said the resident showed signs of anxiousness, restlessness, was fidgety, and could not get comfortable for long periods of times. He said she kept taking off her O2 and thought that was what was causing her behavior. He said he was just going to monitor the resident and did not contact the physician. In a telephone interview on [DATE] at 4:52 p.m., the Medical Director/Attending Physician said he did not personally receive a telephone call about the resident on Sunday, [DATE]. In a follow-up telephone interview, on [DATE] at 5:16 p.m., the Medical Director/Attending Physician said the Nurse Practitioner on call, did not receive a text message or phone call regarding CR #1 on Sunday, [DATE]. He said he was notified today, [DATE], that CR #1 passed away. In a telephone interview on [DATE] at 7:51 a.m., the Nurse Practitioner said on [DATE] he was on-call but was not notified about CR #1's passing on [DATE]. He said he found out the resident passed away yesterday, [DATE]. He said he was at the facility on Monday, [DATE], and no one said anything. In a follow-up interview on [DATE] at 12:01 p.m., the Hospice Nurse said based on the nursing progress note dated [DATE] at 10:51 a.m., the facility should have notified her about the resident's change in condition but did not. She said they should have notified her because it sounded like CR #1 was restless and needed hospice to lay eyes on her. She said if the interventions in place were effective, then they would not have had to call but if it was a continuous problem, they should have called to say crisis was needed. In an interview on [DATE] at 2:45 p.m., the ADON said O2 at ,d+[DATE]L/min continuous was an intervention put into place to help CR#1 breathe. In a follow-up interview on [DATE] at 10:38 a.m., the Nurse Practitioner said based on CR #1's progress note, dated [DATE] at 10:51 a.m., he would have asked staff if they were giving CR #1 breathing treatments, what her lungs sounded like, recommended a chest x-ray, and probably ordered stat labs. He said from what the progress note described, it sounded like she was in mild distress with respiratory and anxiety affecting each other. He said considering her known comorbidities of lung cancer and COPD, a saturation rate of 90% was not unexpected. He said staff knew that a resident with a change in condition, with an emergent concern, must make personal contact with the provider at that time. He said if they were to have mentioned that they were thinking of administering Haldol, he would have recommended that they held off on administration. He said this was all hypothetical as he was not notified. In a follow-up interview, on [DATE] at 4:03 p.m., Nurse C said he checked CR #1's O2 orders but when he increased it to 4 L/min she gave him a look as if it was uncomfortable for her to be at that level. He said in the past she had told him 4 L/min was uncomfortable. He said the physician was not notified at that time because he was going to continue to monitor. The Administrator was notified on [DATE] at 3:35 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on [DATE] at 4:13 p.m. and included: PLAN OF REMOVAL: F695 Name of facility: [] Date: [DATE] Immediate action: F 695 Resident CR#1 was deceased at the time the IJ was issued. A facility audit initiated by the Director of Nursing/Designee on [DATE] of all residents receiving oxygen therapy to assure that the order entered matches the amount of oxygen being received. Physician orders and care plans reviewed and updated if indicated. Any identified issues related to discrepancies in orders or care plans will be addressed as identified with primary care provider notification by DON/Designee if indicated. In-services initiated by DON/Designee on [DATE] with licensed nursing staff present in facility related to Changes in Resident Conditions including identification of respiratory distress and steps to take if current orders do not alleviate symptoms, Physician notification, Administration of Oxygen Therapy, Interact System, and Accidents. The regional nurse consultant in-serviced the Nursing Administration team on [DATE] related to monitoring change in condition forms and progress notes to identify any residents that have experienced respiratory distress to assure that appropriate steps were followed until residents' distress was relieved. Ad Hoc QAPI meeting to be completed with IDT and Medical Director on [DATE]. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: -Audit to be completed [DATE] by DON/Designee to identify any residents receiving Oxygen Therapy. -Education was completed with the administrative nursing team by the Regional Nurse Consultant on [DATE] related to supervision in order to assure that resident changes in condition are addressed promptly and appropriately, and monitoring new oxygen orders and changes to existing oxygen orders to assure that resident is receiving correct dose. -In-services initiated by DON/Designee on [DATE] with licensed nursing staff present in facility related Changes in Resident Conditions including residents receiving hospice services, MD notification, Administration of Oxygen Therapy, Interact System, and Accidents. The DON and/or designee will follow up in the morning clinical meeting to ensure compliance with all clinical processes/systems. LVN A and RN A to be given disciplinary action and trained one on one by Regional Nurse Consultant and/or designee by [DATE]. -Nursing Administration team to monitor change in condition forms and progress notes to identify any residents that have experienced respiratory distress to assure that appropriate steps were followed until residents' distress was relieved. -This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working by [DATE]. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored on [DATE]. Monitoring of the POR included: Record review of in-service that discussed completion of assessments prior to moving unless in respiratory distress, required notifications, and other required documentation, dated [DATE] and [DATE], revealed 10 signatures. Record review of in-service, dated [DATE], titled Interact: Change in Condition, When to Report to The MD/NP/PA revealed 30 signatures. During interviews on [DATE], the following nurses were able to verbalize an understanding of change in condition, physician notification, and oxygen orders: Nurse A, B, C, D, E, F, G, H, and I. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:35 p.m. While the IJ was removed on [DATE] at 2:31 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 5 residents reviewed for resident rights. -The facility failed to notify CR #1's physician when CR #1 became weak, confused, and short of breath which resulted in CR #1 falling and passing away at the facility on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not receiving appropriate care, interventions, and/or death. The findings included: Record review of CR #1's Admission Record, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses included chronic obstructive pulmonary disease (obstructive airflow from the lungs) with acute exacerbation (sudden worsening of COPD symptoms), anxiety disorder, acute and chronic respiratory failure with hypoxia (condition where the lungs and the blood cannot exchange enough oxygen, causing low oxygen levels in the blood and tissues), and malignant neoplasm of unspecified kidney, except renal pelvis (cancer that affects the kidney, excluding the part that connects to the ureter). Record review of CR #1's MDS assessment, dated [DATE], revealed Section C, C0100, BIMS was not completed. Further review revealed resident required one-person assist with mobility, transferring, and setup help with toileting. Record review of CR #1's physician orders, undated, reflected in part .haloperidol tablet 5 mg, give 1 tablet by mouth every 4 hours as needed for mental disorder related to anxiety disorder, start date [DATE] .morphine sulfate (concentrate) oral solution 20 mg/ml, give 1 ml by mouth every 1 hours as needed for pain, start date [DATE] ., albuterol sulfate HFA inhalation aerosol solution 108, 2 puff inhale orally one time a day for COPD, start date [DATE] .methadone HCL tablet 10 mg, give 1 tablet by mouth three times a day for pain, start date [DATE] .ipratropium-albuterol inhalation solution 0XXX,d+[DATE].5 (3) mg/ml, 1 application inhale orally every 6 hours as needed for SOB/wheezing .O2 per nc at ,d+[DATE]L/min continuous. Check O2 sat qshift. Goal to maintain O2 sats >90%, start date [DATE] .house MD to assume care, start date [DATE] . Record review of CR #1's Care Plan, undated, included the following: -CR #1 had COPD r/t smoking. Interventions included: aerosol or bronchodilators as ordered, monitoring for s/sx for acute respiratory insufficiency and infection and oxygen as ordered. -CR #1 had a terminal prognosis r/t liver and kidney cancer and was under hospice services. Interventions included: working cooperatively with hospice team to ensure the resident's emotional, intellectual, and physical needs were met. -CR #1 had an ADL self-care deficit r/t progression of cancer. Interventions included: resident required 1 staff assist with bed mobility, transferring, and toileting and monitoring/documenting/reporting PRN declines in function. -CR #1 had limited physical mobility r/t disease progression. Intervention noted resident was weight bearing. -CR #1 had fluid overload or potential fluid overload r/t kidney failure and liver cancer. Interventions included: monitoring and recording vital signs, notifying MD of significant abnormalities, monitoring/documenting/reporting PRN and s/sx mood/behavior changes, confusion, shortness of breath, difficulty breathing, increased respirations, and difficulty breathing when lying flat. -CR #1 was a high risk for falls related to liking to keep bed in high position, weakness with expected continue to decline. Interventions included: continually educate the resident regarding safety issues and monitoring for any changes in mental, emotional, or physical condition, and monitoring medications for side effects that could contribute to a fall. -CR #1 had an actual fall on [DATE] due to terminal restlessness at 0400 a.m. and another one on [DATE] (time not specified). Interventions included: encouraging resident to not sit on side of the bed or getting up without assistance and monitoring/documenting/reporting PRN x 72h to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, all with a date initiated of [DATE]. -CR #1 used an anti-anxiety medication r/t anxiety disorder. Interventions included: administer medications as ordered, monitor for side effects and effectiveness Q-Shift. Monitor the resident safety. The resident is taking anti-anxiety medications associated with an increased risk of confusion, loss of balance, increased risk of falls, and monitor/document/report PRN any adverse actions to anti-anxiety therapy: drowsiness, lack of energy, slurred speech, and confusion. Record review of CR #1's incident assessment, completed by Nurse C, dated [DATE] 12:20, read in part .found on floor in prone position at the foot of her bed .unable to give description .assisted to bed x2 personnel and cleaned .continuous O2 placed via nasal canula at 3L/min .unresponsive at the time however breathing is at 6 to 8 bpm. Notified hospice of fall and current status. Laceration face . Administrator notified at 12:40 p.m. and Hospice Care notified at 12:30 p.m. on [DATE]. Record review of CR #1's progress note, dated [DATE] 10:51, read in part .Resident very weak, confused and SOB. Resident O2 @90% on 3L/min .Resident given prn dose morphine and Haldol. Resident visibly anxious. Resident continues to sit at the edge of her bed and then laying backwards, causing resident to lay in a perpendicular manner while at the same time being flat on her back. Throughout shift nursing staff and NOD continue to make sure residents head is raised and is not laying perpendicular in bed. Vitals O2 @90% on 3L/MIN, BP-,d+[DATE], Pulse-96, resp labored at 22. Resident continuously reminded to not sit on side of bed and to keep head elevated. Will continue to monitor . Record review of CR #1's progress note, dated [DATE] 2:20 p.m., read in part .NOD was in hall .heard a faint male voice yelling coming from resident's room .nurse immediately walked into resident's room .and immediately saw [CR #1] laying prone at the foot of her bed with a small pool of blood collecting on the floor surrounding resident's facial area. Nurse then immediately notified NOD via cellphone to call NOD .NOD noted resident prone on floor with bleeding coming from resident's facial area. Resident was breathing with a pace of 6 to 8 breaths per minute. Resident noted to have a laceration on the bridge of her nose. Resident slowly helped back to her bed where she was immediately cleaned up and oxygen placed to aide in oxygen saturation. NOD asked Resident's roommate on how resident ended up on the floor in the prone position. Resident's roommate stated, she got up onto her wheelchair and then faceplanted right away after getting onto her wheelchair. Resident breath rate low at 6 bpm. Resident would then slowly stop breathing 20 minutes later, resident's pulse not able to be palpated 20 minutes after fall. Time of death 1240. Notified hospice, family, and admin . In a telephone interview on [DATE] at 1:17 p.m., Nurse C said CR #1 was found lying face down on the floor of her room on [DATE] by Nurse A. He said he was on a different hall performing blood sugar checks at the time of the incident. He said Nurse B called him and told him CR #1 was found on the floor. He said when he entered CR #1's room, he saw her lying face down near the foot of her bed. He said she was unconscious, breathing, and there was a small pool of blood near her head. He said it appeared CR #1 had fallen onto the floor. He said Nurse A and him placed CR #1 in the recovery position [on her side]. He said he called CNA A and told her they needed her help. He said CNA A, Nurse A, and himself transferred CR #1 to her bed. He said once the resident was transferred back onto her bed, her O2 was placed back on her with continuous oxygen at 3L/min and the HOB was elevated. He said the resident was cleaned up and noted to have a laceration on the bridge of her nose. He said when the O2 was placed back on CR #1, she was breathing at a low pace of 6 to 8 breaths per minute. He said he asked CR #1's roommate what happened, and he told him she got up onto her wheelchair and then faceplanted right away after getting onto her wheelchair. He said he called and notified the hospice nurse and Administrator of the incident. He said the day before, Saturday, [DATE], the resident was lethargic, not able to open her eyes very much the entire day and would continuously sit on the side of her bed with her feet hanging over the side. He said CR #1 was educated on the importance of not sitting on the side of her bed, but CR #1 was unable to retain the information. He said nursing staff made 5-minute rounds around the clock to ensure the resident was not lying flat on her back, or sideways in her bed, and/or her room floor. He said the resident showed signs of anxiousness, restlessness, was fidgety, and could not get comfortable for long periods of times. He said CR #1 kept taking off her O2 and he thought that was what was causing her behavior. He said before the incident, he contacted the hospice company and notified them of the resident's condition. He said he asked hospice if they had critical care nurses that could sit with the resident, and he said he was told they did not provide those type of services. He said he was just going to monitor the resident and did not contact the physician. In a telephone interview on [DATE] at 1:59 p.m., Nurse A said she was performing blood sugar checks at approximately 12:05 p.m. on [DATE] when she heard a crash like noise. She said she heard a man yelling and went down the hallway. She said the calls for help were coming from CR #1's roommate. She said when she entered the room, CR #1 was lying face down with her head in a pool of blood. She said CR #1's head was pointed towards the door and her feet were near the foot of her bed. She said she checked for respirations and a pulse and then called for Nurse C. She said Nurse C and she placed the resident in the recovery position, and she started cleaning the blood off her face. She said Nurse C called CNA A to help them transfer the resident back to her bed. She said all three of them, placed the resident back onto her bed, elevated the head of her bed to 45 degrees, and placed her O2 nasal cannula back on at 3L. She said CR #1 had deep, gasping respirations of 6 to 8 breaths per minute and a laceration to the bridge of her nose. She said CR 1's roommate told Nurse C that she attempted to get into her wheelchair and faceplanted on the ground. She said shortly after CR #1 was transferred back to her bed, she took approximately two more breaths and then slowly stopped breathing. She said the time of death was 12:40 p.m. In a telephone interview on [DATE] at 2:24 p.m., Hospice Nurse said she saw CR #1 the day before she passed away on Saturday, [DATE], sometime between 12p.m. and 4 p.m. She said the resident was doing okay. She said the resident was not displaying any signs of agitation, was not lethargic, was able to open her eyes, and answered questions appropriately. She said she was the on-call nurse that weekend and the day, [DATE], CR #1 fell . She said the facility basically called her to inform her that the resident passed away after she fell and not to report that she had fallen. She said when the nurse (could not recall his name) called her, he told her the resident passed away 20 minutes ago. She said the resident should have been sent to the hospital. She said she felt 911 should have been called and then hospice when the resident fell because she could have sustained a head injury. She said she was not asked about critical care services. She said she went to the facility the day CR #1 passed away. She said the police were in CR #1's room with her family member who was her roommate. She said he was inconsolable and expressed to police that she blead profusely. She said she saw the resident after she passed away and her nose was fractured. She said she believed the resident's death was a result from the fall. In an interview on [DATE] at 3:07 p.m., the ADON, said she had been working at the facility for approximately 3 weeks. She said she was not notified of CR #1's fall. She said the Regional Nurse Consultant was filling in for the DON. She said the DON and/or ADON, the Administrator, Hospice company if the resident was on Hospice, the family/responsible party, and physician should be notified. She said the Regional Nurse Consultant could also be notified. She said the nurse on duty that was assigned to the resident should complete the head-to-toe assessment (check vitals and check for injuries). She said she became aware of the fall on Monday morning, [DATE], when she read the progress notes and risk management report. In an interview on [DATE] at 3:37 p.m., the Regional Nurse Consultant said she was providing oversite for the building until they got an interim DON. She said she was notified about the fall by the Administrator after the resident expired at approximately 1:00 p.m. on Sunday, [DATE]. She said staff did not usually call her about a fall unless they had questions. She said they would typically notify the Administrator, ADON and/or DON. She said the nurse on duty should notify the DON and/or ADON, hospice if receiving services, physician, and family. She also said it varied case by case. She said there could be other notifications that needed to be made, but those were the standard notifications for a routine fall. In an interview on [DATE] at 3:54 p.m., the Administrator said she had been working at the facility since February 27, 2023. She said Nurse C notified her at 1:07 p.m. on Sunday, [DATE], via text message that CR #1 passed away. She said the text message mentioned CR #1 had fallen out of her wheelchair. She said she asked Nurse C to call her. She said she did not recall if the physician and/or hospice was notified. She said Nurse C told her hospice was notified but did not say when they were notified. She said Nurse C did not say whether or not he notified the physician. She said she did not notify the facility's physician because that was what the nurses typically did. She said the facility's accident/incident policy said the physician, family, Administrator, ADON, and Hospice, if they were on services, should be notified. In a telephone interview on [DATE] at 4:52 p.m., the Medical Director/Attending Physician said he did not personally receive a telephone call about CR #1's fall on Sunday, [DATE] or about her passing away. In a follow-up telephone interview, on [DATE] at 5:16 p.m., the Medical Director/Attending Physician said the Nurse Practitioner on call, did not receive a text message or phone call regarding CR #1's fall on Sunday, [DATE]. He said he was notified today, [DATE], that CR #1 passed away. In an interview on [DATE] at 7:37 a.m., CR #1's roommate said on the day of the incident, [DATE], she was getting out of bed, fell , and that was all. He said he guessed she was trying to get up and go to the bathroom. He said she was trying to get in her wheelchair and fell on her face. He said that she was always on oxygen. He said the nurse heard her. He said the nurses tried to revive her but could not and gave her oxygen. He said he did not think CR #1 hurt herself. He said there was a man nurse that was taking care of her. In a telephone interview on [DATE] at 7:51 a.m., the Nurse Practitioner said he was on-call, on [DATE], but was not notified that CR #1's fell or that she passed away on [DATE]. He said he found out CR #1 passed away yesterday, [DATE]. He said he was at the facility on Monday, [DATE], and no one said anything. In a follow-up telephone interview on [DATE] at 9:23 a.m., Nurse C said he contacted hospice after making sure CR #1 was stable which was at approximately 12:25 p.m. on [DATE]. He said 911 was not called because by the time he finished talking to the hospice nurse, about 2 minutes later, the resident had passed away. He said it was a little too late to call 911. In a follow-up interview on [DATE] at 10:38 a.m., the Nurse Practitioner said based on CR #1's progress note, dated [DATE] at 10:51 a.m., he would have asked staff if they were giving CR #1 breathing treatments, what her lungs sounded like, recommended a chest x-ray, and probably ordered stat labs. He said from what the progress note described, it sounded like she was in mild distress with respiratory and anxiety affecting each other. He said considering her known comorbidities of lung cancer and COPD, a saturation rate of 90% was not unexpected. He said once again, he was not contacted. He said writing in a book on Sunday was not contacting the physician knowing they did not go to the facility on Sundays. He said someone was always on call 24 hrs. a day, 7 days a week, 365 days. He said staff knew that a resident with a change in condition, with an emergent concern, must make personal contact with the provider at that time. He said if they were to have mentioned that they were thinking of administering Haldol, he would have recommended that they held off on administration. He said this was all hypothetical as he was not notified. In a follow-up telephone interview on [DATE] at 10:57 a.m., Nurse C said he worked the 6:00 a.m. to 10:00 p.m. shift on Saturday, [DATE]. He said initially there was a small puddle of blood, but the bleeding would not stop. He said they cleaned the resident up after they transferred her to her bed which took a while. He said she was still breathing. He said on Saturday, [DATE], she slowly started to decline but could help a little bit to get back into bed and said her mental state was confused. He said her normal baseline was she would go to the store, gas station, and could make her needs known. He said resident's physician and hospice was not notified on [DATE] at 10:51 a.m. because I'm not sure why. He said he notified hospice after CR #1 passed away. In a follow-up interview on [DATE] at 11:28 a.m., the Administrator said she did not follow-up with the NP or physician to see if they were notified about CR #1 falling or passing away. She said the nurses had first-hand knowledge of the information and the protocol was for them to notify the physician, on-call, and/or NP. She said during the weekend they called the on-call and during the week they called the MD or NP. She said if the MD or NP were out-of-town, they set someone else up for staff to contact. She said there was also a posted list of what the Administrator should be notified of at the nurse's station. In a follow-up interview on [DATE] at 12:01 p.m., the Hospice Nurse said based on the nursing progress note dated [DATE] at 10:51 a.m., the facility should have notified her about the resident's change in condition but did not. She said they should have notified her because it sounded like CR #1 was restless and needed hospice to lay eyes on her. She said if the interventions in place were effective, then they would not have had to call but if it was a continuous problem, they should have called to say crisis was needed. In an interview on [DATE] at 3:21 p.m., CNA B said she had been working at the facility for approximately 1 year. She said she worked on [DATE] from 6:00 a.m. to 10:00 p.m. and worked hall 200. She said she saw CR #1 at approximately 6:00 a.m. and she was sleeping. She said she then saw her between 7:00 a.m. and 7:15 am. and she was still sleeping and did not wake up to eat her breakfast. She said she next saw her around 9:30 a.m. and she was still asleep. She said at approximately 10:30 a.m., her roommate started yelling and said the resident needed help. She said CR #1 was sitting up on the side of her bed and asked her for some water. She said after she gave her some water, she laid back down and covered her up. She said she did not say anything else and went back to sleep. She said the resident showed no signs of distress, restlessness, or anxiousness. She said to her, the resident always seemed short of breath, but she did have her O2 on. She said there were no changes with her breathing that she could tell. She said when she passed out lunch trays between 12:00 p.m. and 12:15 p.m., the resident was still asleep and that was the last time she saw CR #1. She said at approximately 12:30 p.m., she found out the resident fell . She said she worked hall 200 by herself. She said Nurse C and Nurse A worked hall 200 as well. She said CR #1 was not herself that day because she slept a lot. She said she worked on Saturday, [DATE], from 6:00 a.m. to 6:00 p.m. and worked hall 200. She said CR #1 was a little more active this day. She said she was going to the bathroom on her own and ate 1 meal. She said she slept a lot but would not be still in her bed. She said she was not sure if it was because she was hot or cold. She said the resident was only SOB when she tried to go to the bathroom. She said CR #1 was not confused and answered her with a yes and/or no. In a follow-up telephone interview on [DATE] at 12:18 p.m., Nurse A said CR #1 was unconscious when she found her. She said she checked her pulses, and the resident was still breathing and was gasping for air. She said she did not remember what she grabbed, but it was either a blanket, sheet, or towel and she started wiping the blood off from her face so she could breathe better. She said CR #1's face was covered in what she thought was a lot of blood. She said she called Nurse B who called Nurse C. She said Nurse C came within seconds. She said the resident was still unconscious, not able to answer them, but was breathing. She said she noticed the resident had a laceration to her nose after they wiped the rest of the blood from her face. She said CR #1's respirations were approximately 6 to 8 breaths per minute, she was gasping, and working hard to take breaths. She said CR #1 took a couple more breaths and then slowly passed away. She said she did not call 911 because by the time they put CR #1 in bed, she passed away shortly after. She said from the time the resident was transferred back to her bed and to the time she passed away, it was approximately 10 to 15 minutes. She said Nurse C, CNA A, and she were at the CR #1's bedside when she passed away. She said she checked the resident's pulse and respirations, which were impalpable. She said she called it, checked her phone and it was 12:40 p.m., so she called the time of death at 12:40 p.m. She said after she called the time of death, Nurse C stepped out and she assumed it was to make the proper calls. She said she felt there was nothing they could have done to prevent it from happening. She said the same steps would have been taken for a resident that was not on hospice. She said she did not see the resident that day aside from the incident. She said the resident was assigned to Nurse C. She said the night before, [DATE], she heard Nurse C talking about CR #1 and how much she was declining and how he would be surprised if she made it through the night. She said before she left her shift that night, she went in the resident's room at approximately 10:00 p.m. to look at her and she said what he said was true and she was surprised CR #1 made it through the night. On [DATE] at 12:35 p.m., Nurse A called and said if a resident was a full code, once they would have put them back in bed, put the O2 back on them and opened their airway, she would have called 911. She said one of them would have gotten the crash cart. She said if a resident was full code and they stopped breathing, they would have resuscitated or did their best to resuscitate. She said they may have even gotten the electrical device with the pads to put on the resident. She said if the resident was a DNR and did not pass away quickly, they would have called 911, but CR #1 passed away very quickly and very shortly after putting her on her bed. She said they did not have time to call 911. She said by the time 911 would have gotten there, she would have been gone. Record review of the facility's policy titled Accidents and Incidents - Investigating and Reporting, revised [DATE], read in part .Policy Interpretation and Implementation .2 .g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions . Record review of the facility's policy titled Hospice Program, revised [DATE], read in part .10.it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: .c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status .d. Communicating with the hospice provider (and documenting such communications) to ensure that the needs of the resident are addressed and met 24 hours per day. The Administrator was notified on [DATE] at 3:35 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on [DATE] at 4:13 p.m. and included: PLAN OF REMOVAL: F580 Name of facility: [] Date: [DATE] Immediate action: F 580 Resident CR#1 was deceased at the time the IJ was issued. A facility audit to be completed by the Director of Nursing/Designee by [DATE] of all residents having a change in condition within the last 7 days to check for proper physician notification. Physician orders will be reviewed, and care plans will be updated if any issues are identified. Any identified issues related to discrepancies in orders or care plans will be addressed as identified with primary care provider notification by DON/Designee if indicated. In-services initiated by DON/Designee on [DATE] with licensed nursing staff present in facility related to Changes in Resident Conditions including identification of respiratory distress, steps to take if current orders do not alleviate symptoms and consulting with the MD for further instruction. Ad Hoc QAPI meeting completed with IDT and Medical Director on [DATE]. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: -Audit to be completed [DATE] by DON/Designee to identify any residents receiving Oxygen Therapy to assure that the order entered matches the amount of oxygen being received. Any areas of concern will be addressed as identified with primary care provider notification by DON/Designee if indicated. -Education was completed on [DATE] with the administrative nursing team by the Regional Nurse Consultant related to supervision to prevent missed resident changes in condition and physician notification. Education included assuring that resident changes in condition are addressed promptly and appropriately, and monitoring new oxygen orders and changes to existing oxygen orders to assure that resident is receiving correct dose. -In-services initiated by DON/Designee on [DATE] with licensed nursing staff present in facility related Changes in Resident Conditions, steps to take if current orders do not alleviate symptoms and consulting with the MD for further instruction. -The DON and/or designee will follow up in the morning clinical meeting to ensure resident changes in condition are addressed promptly and appropriately and that MD notifications were made if warranted. LVN A and RN A have been given disciplinary action and trained one on one by administrative nursing team. -This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working on [DATE]. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from [DATE] through [DATE]. Monitoring of the POR included: Record review of in-service discussing falls, completion of assessments prior to moving unless in respiratory distress, required notifications, and other required documentation, dated [DATE] and [DATE], revealed 10 signatures. Record review of in-service, dated [DATE], titled Interact: Change in Condition, When to Report to The MD/NP/PA revealed 30 signatures. During interviews on [DATE], the following nurses were able to verbalize an understanding of change in condition and physician notification: Nurse A, B, C, D, E, F, G, H, and I. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:35 p.m. While the IJ was removed on [DATE] at 2:31 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, record reviews and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (CR#1) of five residents reviewed for quality of care. The facility failed to ensure CR#1 received necessary care and treatment for a diabetic foot wound on the 4th toe on his right foot resulting in dry gangrene and bone infection. The facility failed to ensure that no new wounds were acquired at the facility. The 1st right toe, left ischium and left buttock wounds were acquired at the facility. CR#1 was admitted to the ER at local hospital on 9/15/2023 after the Wound care Physician B completed an assessment and found that his wounds were worse than documented by Wound Care Physician A. This failure caused CR#1 to be hospitalized and two leg amputations due to the infected wounds and placed the other four residents at risk for wounds worsening, pain and discomfort. An Immediate jeopardy (IJ) situation was identified on 9/25/2023 at 2:03 p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Findings Included: Record review of a list of in-house wounds provided by the DON on 9/20/23, revealed that the facility listed four residents with non-presure wounds. Record review of CR#1 face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and had diagnoses of osteomyelitis of vertebra (infection of vertebral body of the spine), diabetes mellitus(inadequate control of the blood levels of glucose), chronic kidney disease(kidney are damaged and cannot filter blood), peripheral vascular disease(condition in which narrowed arteries reduce blood flow to the limbs), paraplegia(incomplete), gangrene (not elsewhere classified), pressure ulcer on sacral region(unstageable), deep tissue damage to left heel and right heel, post-surgical wound of the upper back and anemia. Record review of the admission patient care summary dated 2/6/2023 revealed that a local acute hospital reported to the facility that CR#1 had lumbar osteomyelitis (which is the most common form of vertebral infection), surgical wound to the lumbar, sacral wound (unstageable), gangrene 4th right toe, deep tissue injury to left heel, diabetes mellitus (Type 2), and peripheral vascular disease. Plan: Continue local care to right fourth toe and use zinc oxide on left heel and offload while in bed. Record review of CR#1's MDS dated [DATE], revealed that his brief interview of mental status had a score of 15, which meant that he was cognitively intact. His functional ability was coded: Bed mobility, transfers, dressing and toilet use as (3)- extensive assistance and support was coded as (3) for two persons assist. Section H0400 was coded as (2) as CR#1 was frequently incontinent and required assistance of 1 staff. Record review of CR#1's care plan dated 4/10/23 revised revealed it to state in part .CR#1 has pressure injuries on his sacrum that was stage 4 and right heel unstageable. Goal: CR#1 will not have no complications from pressure injuries through the review date. Intervention: Assess for signs and symptoms, elevate with float heels to keep off bed and wheelchair and implement weekly skin checks. ADL's care plan revised on 7/17/2023 read in part .skin inspection weekly to observe for redness, open areas, scratches, cuts, bruises and report any changes to the nurse. Record review of the initial skin assessment upon admitted d 2/20/23 read in part: Right toes had wounds that were considered vascular. It was e-signed by LVN A. There was no reference to the 4th toe. Review of the nursing weekly skin review for CR#1 dated 3/6/2023 listed wounds to the right heel, sacrum, lumbar and the right 4th toe had a wound that was 2.0 in length and 2.0 width. It was e-signed by the former DON. Record review of his medical record revealed this was the first time the #4 toe wound was identified and documented. No treatment was put into place for the 4th right toe. Review of the wound care initial assessment and evaluation for CR#1 competed by Wound care physician A dated 3/20/2023 listed the following wounds: Site #1- Post surgical wound upper back, Site #2- unstageable pressure wound on sacrum, Site #3- unstageable right heel wound, Site # 4 unstageable (due to necrosis) left heel. The right 4th toe was not listed. Record review of the weekly skin evaluations by Wound Care doctor A between 3/13/2023 -9/6/2023 revealed no reference about the wound located on CR#1's right 4th toe. Record review of the nursing weekly skin assessment for CR#1 wounds completed by LVN B dated between 3/27/2023-6/20/2023, listed 1-5 wounds: (sacral, upper back, left heel, right heel and 1st right toe). The right 4th toe wound was not documented. Record review of the nursing weekly skin assessment for CR#1 wounds completed by LVN B dated 6/27/2023-8/14/2023, listed 1-7 wounds:(sacral, upper back, lumbar, left heel, right heel, 1st right toe and left ischium). The right 4th toe wound was not documented. Record review of the Physician order summary for CR#1 for April 1-30/2023, revealed: Left heel wound was added and ordered betadine to wound daily one time day every Monday-Friday for wound healing starting 4/10/2023-5/2/2023. Right 4th toe order changed to -clean wound with cleanser, pat dry, apply betadine cover and secure with island border Monday-Friday 1 time per day. (Start date 4/10/2023) Sacrum order changed to- clean wound with cleanser, pat dry and apply Sodium Hypochlorite solution (Dakin) soaked gauze daily for healing for 30 days. (Start date 4/12/2023) Record review of the treatment administration record for CR#1 dated 4/1/2023-4/30/2023, revealed: Left heel- had no documentation of treatment on 4/11/2023(Tuesday), 4/26/2023(Wednesday) Right 4th toe- no documentation of treatment for the right 4th toe on 4/11/2023(Tuesday) and 4/26/2023 (Wednesday). Sacrum- had no documentation of treatment on 4/15, 4/16, and 4/26/2023. Record review of the physician order summary for CR#1 dated 8/1/2023-8/30/2023 revealed: DTI bilateral toes on left and right foot: apply skin prep three times a week for 16 days (M, W, F)- start date 8/16/2023. Left Buttock pressure wound was added: clean with cleanser, pat dry and apply Medi honey and apply alginate calcium daily for 30 days. Start date: 8/9/2023. Sacrum order changed to clean with cleanser then pack with Vashe wound solution socked gauze for 30 days one time a day for wound healing start date: 8/3/2023. Left Ischium(left hip joint) was added- clean with cleanser, pat dry, apply alginate calcium and cover with bordered gauze dressing daily for 30 days. Record review of Wound administration record for CR#1 dated 9/1-9/30/2023 revealed: Wound care treatment was not documented for the sacrum, left heel, right heel or 4th toe on the right foot on 9/7, 9/10, 9/11, or 9/13/2023. Record review of an initial Wound assessment by Physician B for CR#1 dated 9/15/2023 revealed the following: Site #1 Post surgical wound of the upper back full thickness Site #2 - Stage 4 Pressure wound sacrum - Site #3- Stage 4 Pressure wound on right heel Site #4- Stage 4 Pressure wound of the left heel Site #5 Unstageable DTI of the right 1st toe Site #6 Stage 3 pressure wound of left ischium Site #7 -Wound of the right 4th toe -had purulent drainage The wound care physician wrote: Please transfer to ER due to purulent drainage and worsening wounds. Record review of a grievance dated 8/28/2023, revealed that CR#1 FM had concerns about him not getting daily treatments to his sacrum area, feet, toes and the wounds were getting worse. Record review of communication book located at nursing station revealed that there were no orders or communication concerning CR#1's 4th toe on the right foot or the worsening of his right heel, left heel or sacrum. There were no communications concerning the left ischium, which was newly acquired. Record review of the hospital records for CR#1 revealed he was admitted on [DATE]. His admission diagnosis or concern was multiple diabetic foot wounds that were infected, 4th toe on right foot dry gangrene. Assessment: left and right heel open wound possible calcaneal osteomyelitis, right foot 4th toe osteomyelitis, left and right lower extremity paralysis and type 2 diabetes. Recommendation: Patient advised he has a bone infection to right foot 4th toe. Patient declined right foot 4th toe amputation and calcaneal resection. Biopsy of right toe bone was done on 9/20/2023. Below knee amputations of both left and right legs scheduled for 9/26/2023 due to bacterial bone infection. Observation of CR#1 at a local hospital on 9/20/2023@ 2:40 p.m., revealed that he was receiving wound care at the time. Interview with CR#1 on 9/20/2023 @ 2:55 p.m., revealed he stated that he was not receiving wound treatment as he was supposed to get daily. He stated that the wound to the sacrum and his heels were supposed to be done daily and sometimes he did not receive treatment for days. He stated that the wounds on his right and left heels were badly infected. He said that the right 4th toe was getting better when LVN B was providing care, but when she resigned sometime in August 2023, it got infected again. He said the nurse assigned his hall (Hall 200) was supposed to care for his wounds. He said he felt like they did not want to do his wound treatments. He said that he was sometimes in pain and was given pain medication. He said that his FM filed a grievance because the facility did not provide adequate or daily wound care treatment and said that they had pictures of his wounds before he came to the facility and after. As a result not getting adequate wound treatment, he stated that he was scheduled for two amputations below the knee in two weeks due to bone infection. He said that this had been the worst experience in his life. Interview with LVN C on 9/21/2023 at 1:00 p.m., revealed her to state she did not normally work the Hall (200) where CR#1 resided. She said that the facility wound care nurse had resigned several weeks ago and she learned that the floor nurses were supposed to provide wound care. She said that the usual process was upon arrival of her shift she would review MARS/TARS/WARS in PCC and there was a list of all medications and treatments they had to administer on each shift. She said on 9/13/2023, she logged into Wound Treatment Administration (WAR) to see treatments. She said that she did not see any treatments that were needed for CR#1. She said that she had received disciplinary action or a write up due to the missed treatment for CR#1 on 9/13/2023. She denied observing his wounds. She said that she did not provide treatment for CR#1 and did not usually work his hall. Interview with the new DON on 9/21/2023 at 1:27 p.m., she stated that she had been employed at the facility for about 1 week. She stated that she did rounds with facility physician on or about 9/13/2023 and due to CR#1's wounds having an odor, he ordered antibiotics. She said during these rounds she did notice that one of his toes was black. She said she could not recall which foot or toe. She said she had not reviewed his record prior to the rounds so she was not aware of all the pressure ulcers that he had at the time. She said after reviewing his record, she learned that wound care treatments were missed or not documented by the nurses on 9/7, 9/10, 9/11, and 9/13/2023. She did not see any treatments for the 4th right toe. The missed treatments were for the sacrum and both left and right heels as far as she could tell. She said those nurses had been or will be reprimanded. She said as far as she could tell, RN A, LVN's C and D were the nurses that were scheduled to work and responsible for wound treatment for CR#1 but did not provide the care. She stated that the communication book was used for communication between nurses and physicians. She was informed that no orders or communication was found for CR#1's wound to his 4th toe on the right foot and that the facility used wound administration records to put the treatments necessary for residents. She stated missed wound care treatments can cause increased risk of infection, infections could become worst and residents' health could decline. Interview with the Administrator on 9/21/2023 at 1:40 p.m., she said that Wound Care Physician A was terminated due to inadequate wound care. She stated she learned from her care staff that he was debriding wounds quickly and moving on to the next resident without applying dressing on the wounds. She said that his last day was on or about 9/5/2023. She said the Wound Care Physician B started on 9/15/2023 and after assessing CR#1, he sent him to the hospital. She said that he said that the wounds looked worse than the former wound care physician A had documented and even the sizes were not accurate. She said that the floor nurses were responsible for providing CR#1's wound care between 9/5/2023-9/15/2023 and prior to that LVN B provided the care for several months before resigning. She stated that a PRN wound nurse started on today (9/21/2023) and that she hired a full-time wound nurse that would start in two weeks. She said she had just started to investigate the incident and had a few more days to complete. She stated that the DON would be providing in-services soon. Interview with RN A on 9/21/2023 at 1:54 p.m., she stated that she started working at the facility in July 2023 on 2-10pm shift and recently changed to 6a-2pm shift. She stated that on 9/7/2023 she worked down the Hall where CR#1 resided and once she opened PCC and logged in that it was supposed to tell the nurse which residents needed treatment, area and the physician orders. She stated that she does recall what areas she treated because she does not normally work down Hall 200 and she had not cared for CR#1 before 9/7/2023. She stated that she did not miss any of his treatments, if anything she forgot to click that it was completed. She agreed that if there was no documentation that the treatment was not done. She said that she was not provided any training on providing wound care. She said wound treatment was nursing 101 and that she always provided a head-to-toe assessment when she was not familiar with a resident. However, she could not recall missing his treatments. She stated that any changes or new skin conditions are documented in PCC and this information was reviewed by the DON. She said that she would use the communication book as well to notify the physician and they would also call and text the doctors. Interview with LVN D on 9/21/2023 at 2:06 p.m., revealed that she worked 6am-2pm shift usually down Hall 100. She stated that she was hired to work Hall 100 but was told that she would have to work Halls 200 and 400. She said that she only recalled treating CR#1 maybe once. Halls 200 and 400 had heavy acuity residents. She stated that she recalled that he needed wound treatment of the ischium, heels, and sacrum. She stated that she provided treatment on or before 9/13/2023. She said she could not recall. She stated that any changes to the residents' wounds were documented in PCC and in the communication book. She stated that missed treatments could cause infections, and discomfort. Interview with the Regional Nurse on 9/21/2023 on 2:55 p.m., she stated that she was unable to locate an order for wound treatment of the 4th toe on the right foot after she searched through almost two months of orders. She stated that the process was that any telephone orders are placed in a communication binder. She said from there the medical records coordinator input the information into PCC and the DON would check the e-fax and update the care plan. She stated that she was not sure why the nurses were not providing treatments as ordered. She said that the floor nurses were supposed to provide wound care as the physician ordered. She said that wound care treatments missed or not provided can cause wounds to get worst and infections. Interview with FM on 9/22/2023 at 11:56am, FM stated that she visited with CR#1 nearly every day. FM said when he was first admitted to the facility, he only had one surgical wound that was not healed. FM said in the past he did have a sacrum wound that was very small and was not opened. FM stated sometime around June 2023, FM had noticed that staff were not re-positioning him as he was always in the bed when FM visited, and no one came in to turn him while FM was there. FM visited with CR#1 between 3-4 hours daily. FM said that his wound on the sacrum was opened and had an odor on or around July 2023. FM talked to the former DON about his care. FM said the DON assured her that they were working on his wounds to get them better and FM spoke with LVN B, who was the wound care nurse, and she also said his wounds were getting better. FM said that his wounds on his heels were like hard callus and was told at the previous hospital that he resided that they were fine if they were not opened. FM said they were not infected because FM would often rub his feet and heels with lotion to soften the callused skin. FM learned that the wound care doctor had debrided his heels and they were now opened and infected from a CNA (which she could not name) and that his 4th right toe had turned to dark color. FM stated that CR#1 heels were bandaged and that is why the condition of them were not known for a few weeks. FM said CR#1 did not have a wound vac that he was supposed to have and that felt like that was because he started having issues with his insurance around August 2023. FM said that with all the staff turnover she could not recall all the names of the people spoken to on CR#1's behalf (but mostly nurses and aides). FM does not recall speaking with the Administrator. FM stated that around the beginning of August 2023, she was trying to find another facility to have him transferred. FM said that it was difficult to find a facility that would take CR#1 because of all the wounds he had acquired while at the facility. FM said that his feet was wrapped most of time but do not recall boots being on his heels. Interview with LVN B on 9/25/2023 at 6:48 p.m., she stated that she started working at the facility March 2023. She stated that she did wound treatments for CR#1. She stated that she was not certified to complete wound care. She stated that CR#1 had wounds to his heels, sacral, upper back had a surgical wound, and she recalled the 1st right toe. She said that the heels were only getting betadine for awhile until they were debrided. She said that the worse wounds were the sacral area and the heels after the debridement. She stated that the facility administration expected her to provide wound care, pass medications, take vitals and weights, and overall patient care on halls 200 and 400 was hard because the residents on those halls had the highest acuity. She stated that she had a stroke several months ago and it forced her to recognize that she had been under a lot of stress working at the facility, which is why she resigned. She stated that she did not recall the exact treatments for every wound without access to PCC. Interview with the facility Physician on 9/26/2023 at 2:01pm, he stated that his NP provided a referral for Wound care Physician A to start treating CR#1 wounds when he was admitted . He stated that he was currently the facility physician and the MD. He said that he was aware of the wound on the right 4th toe and that at some point it had gotten better. He said that his wounds were cared for by the Wound care doctor. He stated that the Administrator made him aware that she terminated the services of Wound care physician A on or about 9/5/2023. He said that she did not say why she no longer wanted his services, and he did not ask. He said that he assessed CR#1 again to assume care until the administrator found another doctor on or about 9/6/2023. He stated that once he made a referral for wound care that physician would provide all the wound care services. He attempted to pull up CR#1's records on his phone. He said that it was a HIPAA violation to show his record, but that anytime he observed a new wound on CR#1 it was documented, and orders were placed as needed. He stated that he would send an e-fax and it would be directly uploaded into the facility's PCC system. He said that he was not aware of any issues with orders were not in the system. He was then made aware that no orders were found for CR#1's 4th right toe, and wounds on his left and right heels and sacrum were worse than when CR#1 was admitted . He said that he was made aware of the issues after wound care doctor A was terminated. Interview with Wound Care Physician B on 9/28/23 at 3:26pm, revealed him to state that on 9/15/23, he conducted an assessment on CR#1. He stated that from the current documentation from former Wound Care Physician A, the sacral wound was measured larger than the documentation showed and the wound on right foot (4th toe) was having purulent drainage and he did not see any documentation, multiple wounds for a complex patient, high risk with drainage was his reason for sending his to the hospital. He stated that he thought the most appropriate thing for him to do was send him to have advanced imaging and possible surgical evaluation. He said that it was appropriate to escalate care based on those issues. He stated that he consulted with the facility due to a referral by the facility physician on only residents that the facility wants him to consult. He said that he does not see all residents that have wounds in the facility. Post surgical wounds are usually handled by the facility doctor and he does not care for those same residents. Interview with hospital surgeon on 9/28/2023 at 5:07pm, he stated that he was a vascular surgeon. He stated that he performed the below knee amputations(BKA) of both of CR#1's left and right legs. He said that his pressure ulcers on the left and right heels were deep in the tissue and badly infected. He said the bone infection was very serious and amputating the limbs were the only option. He said that he maintained the knees so CR#1 could possibly use prosthetics in the future. He said that the wounds were not adequately cared for by the facility where CR#1 resided. He said that he could tell that there could not have been heel supports used to keep his heels from the bed and the facility staff probably did not reposition him as needed. He said that although the resident had peripheral vascular disease, his blood flow was not an issue. He stated that the SW had a statement in his chart to find alternate placement upon his discharge and he agreed. He said that he will need to go to a facility that will properly care for his wounds. An Immediate jeopardy (IJ) situation was identified on 9/25/2023 at 2:03p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. The adminsitrator was provided a copy of the template and plan of removal. Immediate action taken: Resident #1 had been discharged to the hospital on 9/16/23 and had not returned to the facility at the time the immediate jeopardy was issued. Once resident #1 was seen by the wound care doctor on 9/16/23, an order to send to the ER for evaluation was given and implemented immediately. A facility audit of all residents to be completed by the Director of Nursing/Designee by 9/25/2023 of all residents to validate a skin check has been completed in the past 7 days and that any areas identified had been communicated to the physician. Any resident who has not had a documented skin check within the past 7 days had a skin check completed by Regional Nurse Consultant and/or DON on 9/25/2023. The facility reviewed/revised the system for receiving orders from the physician and communicating with the physician more efficiently and effectively. The facility created a plan of improvement to address changes including acceptable methods of communication, order transcription and use of order binder. Care plan audit for all residents with wounds to be completed on 9/26/23 by MDS coordinator and Regional MDS support to assure that the CP matches current wounds and interventions. Nursing administration to initiate acute care plans and IDT to monitor and assure that care plans are updated timely. In-services initiated 9/26/23 with administrative nursing team related to completion and updating of acute and chronic wound care plans Ad Hoc QAPI meeting completed with IDT, Regional Nurse Consultant and Medical Director on 9/26/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: Skin checks were completed by DON/designee on 9/25/23 including 100% of residents in the facility with no unknown wounds discovered. A facility wound audit was completed on 9/25/2023 to validate all wounds had current and appropriate treatment. Education was initiated for the facility nursing staff by Administrator/designee on 9/25/23 related to ensuring all resident's health and safety are protected from abuse and neglect*. Education was initiated for Nursing Assistants by DON/designee on 9/25/2023 on ensuring residents at high risk for skin breakdown are turned and repositioned at least every two hours, how to provide proper bathing/personal cares with residents with wounds, who to notify if skin breakdown is identified and using the Stop and Watch tool in POC to alert nurse*. Education was initiated for the DON by the Regional Nurse Consultant related to oversight of the wound care program on 9/25/23. Education to be initiated by DON/Designee on 9/25/2023 with all Licensed Nurses regarding changes in resident condition, the importance of completing a thorough weekly skin assessment, completing, and documenting wound care per physician orders, validating that all wounds have orders for treatment, reporting immediately when a resident has incurred a skin impairment notifying the doctor of new or worsening skin areas, and proper documentation*. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working 9/25/2023. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. Monitoring included: Record review of an in-service on 9/25/2023 revealed, Regional Nurse conducted oversight of wound care program, required documentation, interventions and follow-up with DON. All wounds must have care plans that indicate the location and etiology of each wound present. Interventions must be updated in a timely manner. Record review of an in-services on 9/25/2023, revealed Regional nurse covered stop and watch documentation of new alterations in skin integrity. Skin breakdown prevention, turning and repositioning residents at high risk of skin breakdown, change in condition, completing wound assessments, validating wound orders, reporting new wounds and documenting. Interviews were conducted between 9/26/2023-9/28/2023 with 3 CNA's, 4 LVN's, 2 RN's on day, evening and night shifts. They reported that they were in-serviced on observing wounds, documenting, stop and watch, reporting changes to physicians, accurate weekly assessments, abuse, neglect and exploitation as well as protocol for pressure wounds. They were able to verbalize their understanding of the in services provided. Subsequent interview with the Administrator on 9/28/2023 at 12:25pm, she stated that after all physician visits to the facility, they will leave a visit summary. The summaries will also be emailed and followed up by the DON. She said that their system will get better and so treatments were adequate and timely for residents. Subsequent interview with the DON on 9/28/2023 at 12:55pm, she stated that she was aware that it was her responsibility to ensure physician orders complete and that there was a care plan for wounds, treatments were conducted timely and without any missed treatments. She said that she was still new but will learn the system and work with staff to make the facility better. An Immediate jeopardy (IJ) situation was identified on 9/25/2023 at 2:03p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system.

Based on observation, interview and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1(CR#1) of 5 residents reviewed for pressure ulcers. The facility failed to ensure that no new pressure wounds were acquired at the facility. The 1st right toe, left ischium and left buttock wounds were acquired at the facility. CR#1 was admitted to the ER at local hospital on 9/15/2023 after the Wound care Physician B completed an assessment and found that his wounds were worse than documented by Wound Care Physician A. This failure caused (CR#1) bone infection and placed other residents at risk for pain, worsening wounds, infection, emotional distress and harm. An Immediate Jeopardy (IJ) situation was identified on 9/25/2023 at 2:03 p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Findings Included: Record review of a list of in-house wounds provided by the DON on 9/20/23, revealed that the facility listed four residents with pressure wounds. Record review of CR#1 face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and had diagnoses of osteomyelitis of vertebra (infection of vertebral body of the spine), diabetes mellitus(inadequate control of the blood levels of glucose), chronic kidney disease(kidney are damaged and cannot filter blood), peripheral vascular disease(condition in which narrowed arteries reduce blood flow to the limbs), paraplegia(incomplete), gangrene (not elsewhere classified), pressure ulcer on sacral region(unstageable), deep tissue damage to left heel and right heel, post-surgical wound of the upper back and anemia. Record review of the admission patient care summary dated 2/6/2023 revealed that a local acute hospital reported to the facility that CR#1 had lumbar osteomyelitis (which is the most common form of vertebral infection), surgical wound to the lumbar, sacral wound (unstageable), gangrene 4th right toe, deep tissue injury to left heel, diabetes mellitus (Type 2), and peripheral vascular disease. Plan: Continue local care to right fourth toe and use zinc oxide on left heel and offload while in bed. Record review of CR#1's MDS dated [DATE], revealed that his brief interview of mental status had a score of 15, which meant that he was cognitively intact. His functional ability was coded Bed mobility, transfers, dressing and toilet use as (3)- extensive assistance and support was coded as (3) for two persons assist. Section H0400 was coded as (2) as CR#1 was frequently incontinent and required assistance of 1 staff. Record review of CR#1's care plan dated 4/10/23 revised revealed it to state in part .CR#1 has pressure injuries on his sacrum that was stage 4 and right heel unstageable. Goal: CR#1 will not have no complications from pressure injuries through the review date. Intervention: Assess for signs and symptoms, elevate with float heels to keep off bed and wheelchair and implement weekly skin checks. ADL's care plan revised on 7/17/2023 read in part .skin inspection weekly to observe for redness, open areas, scratches, cuts, bruises and report any changes to the nurse. Review of the nursing weekly skin review for CR#1 dated 3/6/2023 listed wounds to the right heel, sacrum, lumbar and the right 4th toe had a wound that was 2.0 in length and 2.0 width. It was e-signed by the former DON. Record review of his medical record revealed this was the first time the #4 toe wound was identified and documented. Review of the wound care initial assessment and evaluation for CR#1 competed by Wound care physician A dated 3/20/2023 listed the following wounds: Site #1- Post surgical wound upper back, Site #2- unstageable pressure wound on sacrum, Site #3- unstageable right heel wound, Site # 4 unstageable (due to necrosis) left heel. Record review of the nursing weekly skin assessment for CR#1 wounds completed by LVN B dated between 3/27/2023-6/20/2023, listed 1-5 wounds: (sacral, upper back, left heel, right heel and 1st right toe). Record review of the nursing weekly skin assessment for CR#1 wounds completed by LVN B dated 6/27/2023-8/14/2023, listed 1-7 wounds:(sacral, upper back, lumbar, left heel, right heel, 1st right toe and left ischium). Record review of the Physician order summary for CR#1 for April 1-30/2023, revealed: Left heel wound was added and ordered betadine to wound daily one time day every Monday-Friday for wound healing starting 4/10/2023-5/2/2023. Right 4th toe order changed to -clean wound with cleanser, pat dry, apply betadine cover and secure with island border Monday-Friday 1 time per day. (Start date 4/10/2023) Sacrum order changed to- clean wound with cleanser, pat dry and apply Sodium Hypochlorite solution (Dakin) soaked gauze daily for healing for 30 days. (Start date 4/12/2023) Record review of the treatment administration record for CR#1 dated 4/1/2023-4/30/2023, revealed: Left heel- had no documentation of treatment on 4/11/2023(Tuesday), 4/26/2023(Wednesday) Sacrum- had no documentation of treatment on 4/15, 4/16, and 4/26/2023. Record review of the physician order summary for CR#1 dated 8/1/2023-8/30/2023 revealed: DTI bilateral toes on left and right foot: apply skin prep three times a week for 16 days (M, W, F)- start date 8/16/2023. Left Buttock pressure wound was added: clean with cleanser, pat dry and apply Medi honey and apply alginate calcium daily for 30 days. Start date: 8/9/2023. Sacrum order changed to clean with cleanser then pack with Vashe wound solution socked gauze for 30 days one time a day for wound healing start date: 8/3/2023. Left Ischium(left hip joint) added- clean with cleanser, pat dry, apply alginate calcium and cover with bordered gauze dressing daily for 30 days. Record review of Wound administration record for CR#1 dated 9/1-9/30/2023 revealed: Wound care treatment was not documented for the sacrum, left heel, right heel or 4th toe on the right foot on 9/7, 9/10, 9/11, or 9/13/2023. Record review of an initial Wound assessment by Physician B for CR#1 dated 9/15/2023 revealed the following: Site #1 Post surgical wound of the upper back full thickness Site #2 - Stage 4 Pressure wound sacrum Site #3- Stage 4 Pressure wound on right heel Site #4- Stage 4 Pressure wound of the left heel Site #5 Unstageable DTI of the right 1st toe Site #6 Stage 3 pressure wound of left ischium Site #7 -Wound of the right 4th toe -had purulent drainage The wound care physician wrote: Please transfer to ER due to purulent drainage and worsening wounds. Record review of a grievance dated 8/28/2023, revealed that CR#1 FM had concerns about him not getting daily treatments to his sacrum area, feet, toes and the wounds were getting worse. Record review of communication book located at nursing station revealed that there were no orders or communication concerning CR#1's 4th toe on the right foot or the worsening of his right heel, left heel or sacrum. There were no communications concerning the left ischium or left buttock or 1st right toe, which were acquired at the facility. Record review of the hospital records for CR#1 revealed he was admitted on [DATE]. His admission diagnosis or concern was multiple diabetic foot wounds that were infected. Assessment: left and right heel open wound possible calcaneal osteomyelitis, right foot 4th toe osteomyelitis, left and right lower extremity paralysis and type 2 diabetes. Recommendation: Patient advised he has a bone infection to right foot 4th toe. Patient declined right foot 4th toe amputation and calcaneal resection. Biopsy of right toe bone was done on 9/20/2023. Below knee amputations of left and right legs were to be performed on 9/26/2023 due to bacterial bone infection. Observation of CR#1 at a local hospital on 9/20/2023@ 2:40 p.m., revealed that he was receiving wound care at the time. Interview with CR#1 on 9/20/2023 @ 2:55 p.m., revealed he stated that he was not receiving wound treatment as he was supposed to get daily. He stated that the wound to the sacrum and his heels were supposed to be done daily and sometimes he did not receive treatment for days. He stated that the wounds on his right and left heels were badly infected. He said that the right 4th toe was getting better when LVN B was providing care, but when she resigned sometime in August 2023, it got infected again. He said the nurse assigned his hall (Hall 200) was supposed to care for his wounds. He said he felt like they did not want to do his wound treatments. He said that he was sometimes in pain and was given pain medication. He said that his FM filed a grievance because the facility did not provide adequate or daily wound care treatment and said that they had pictures of his wounds before he came to the facility and after. As a result not getting adequate wound treatment, he stated that he was scheduled for two amputations below the knee in two weeks due to bone infection. He said that this had been the worst experience in his life. Interview with LVN C on 9/21/2023 at 1:00 p.m., revealed her to state she did not normally work the Hall (200) where CR#1 resided. She said that the facility wound care nurse had resigned several weeks ago and she learned that the floor nurses were supposed to provide wound care. She said that the usual process was upon arrival of her shift she would review MARS/TARS/WARS in PCC and there was a list of all medications and treatments they had to administer on each shift. She said on 9/13/2023, she logged into Wound Treatment Administration (WAR) to see treatments. She said that she did not see any treatments that were needed for CR#1. She said that she had received disciplinary action or a write up due to the missed treatment for CR#1 on 9/13/2023. She denied observing his wounds. She said that she did not provide treatment for CR#1 and did not usually work his hall. Interview with the new DON on 9/21/2023 at 1:27 p.m., she stated that she had been employed at the facility for about 1 week. She stated that she did rounds with facility physician on or about 9/13/2023 and due to CR#1's wounds having an odor, he ordered antibiotics. She said during these rounds she did notice that one of his toes was black. She said she could not recall which foot or toe. She said she had not reviewed his record prior to the rounds so she was not aware of all the pressure ulcers that he had at the time. She said after reviewing his record, she learned that wound care treatments were missed or not documented by the nurses on 9/7, 9/10, 9/11, and 9/13/2023. She did not see any treatments for the 4th right toe. The missed treatments were for the sacrum and both left and right heels as far as she could tell. She said those nurses had been or will be reprimanded. She said as far as she could tell, RN A, LVN's C and D were the nurses that were scheduled to work and responsible for wound treatment for CR#1 but did not provide the care. She stated that the communication book was used for communication between nurses and physicians. She was informed that no orders or communication was found for CR#1's wound to his 4th toe on the right foot and that the facility used wound administration records to put the treatments necessary for residents. She stated missed wound care treatments can cause increased risk of infection, infections could become worst and residents' health could decline. Interview with the Administrator on 9/21/2023 at 1:40 p.m., she said that Wound Care Physician A was terminated due to inadequate wound care. She stated she learned from her care staff that he was debriding wounds quickly and moving on to the next resident without applying dressing on the wounds. She said that his last day was on or about 9/5/2023. She said the Wound Care Physician B started on 9/15/2023 and after assessing CR#1, he sent him to the hospital. She said that he said that the wounds looked worse than the former wound care physician A had documented and even the sizes were not accurate. She said that the floor nurses were responsible for providing CR#1's wound care between 9/5/2023-9/15/2023 and prior to that LVN B provided the care for several months before resigning. She stated that a PRN wound nurse started on today (9/21/2023) and that she hired a full-time wound nurse that would start in two weeks. She said she had just started to investigate the incident and had a few more days to complete. She stated that the DON would be providing in-services soon. Interview with RN A on 9/21/2023 at 1:54 p.m., she stated that she started working at the facility in July 2023 on 2-10pm shift and recently changed to 6a-2pm shift. She stated that on 9/7/2023 she worked down the Hall where CR#1 resided and once she opened PCC and logged in that it was supposed to tell the nurse which residents needed treatment, area and the physician orders. She stated that she does recall what areas she treated because she does not normally work down Hall 200 and she had not cared for CR#1 before 9/7/2023. She stated that she did not miss any of his treatments, if anything she forgot to click that it was completed. She agreed that if there was no documentation that the treatment was not done. She said that she was not provided any training on providing wound care. She said wound treatment was nursing 101 and that she always provided a head-to-toe assessment when she was not familiar with a resident. However, she could not recall missing his treatments. She stated that any changes or new skin conditions are documented in PCC and this information was reviewed by the DON. She said that she would use the communication book as well to notify the physician and they would also call and text the doctors. Interview with LVN D on 9/21/2023 at 2:06 p.m., revealed that she worked 6am-2pm shift usually down Hall 100. She stated that she was hired to work Hall 100 but was told that she would have to work Halls 200 and 400. She said that she only recalled treating CR#1 maybe once. Halls 200 and 400 had heavy acuity residents. She stated that she recalled that he needed wound treatment of the ischium, heels, and sacrum. She stated that she provided treatment on or before 9/13/2023. She said she could not recall. She stated that any changes to the residents' wounds were documented in PCC and in the communication book. She stated that missed treatments could cause infections, and discomfort. Interview with the Regional Nurse on 9/21/2023 on 2:55 p.m., she stated that she was unable to locate an order for wound treatment of the 4th toe on the right foot after she searched through almost two months of orders. She stated that the process was that any telephone orders are placed in a communication binder. She said from there the medical records coordinator input the information into PCC and the DON would check the e-fax and update the care plan. She stated that she was not sure why the nurses were not providing treatments as ordered. She said that the floor nurses were supposed to provide wound care as the physician ordered. She said that wound care treatments missed or not provided can cause wounds to get worst and infections. Interview with FM on 9/22/2023 at 11:56am, FM stated that she visited with CR#1 nearly every day. FM said when he was first admitted to the facility, he only had one surgical wound that was not healed. FM said in the past he did have a sacrum wound that was very small and was not opened. FM stated sometime around June 2023, FM had noticed that staff were not re-positioning him as he was always in the bed when FM visited, and no one came in to turn him while FM was there. FM visited with CR#1 between 3-4 hours daily. FM said that his wound on the sacrum was opened and had an odor on or around July 2023. FM talked to the former DON about his care. FM said the DON assured her that they were working on his wounds to get them better and FM spoke with LVN B, who was the wound care nurse, and she also said his wounds were getting better. FM said that his wounds on his heels were like hard callus and was told at the previous hospital that he resided that they were fine if they were not opened. FM said they were not infected because FM would often rub his feet and heels with lotion to soften the callused skin. FM learned that the wound care doctor had debrided his heels and they were now opened and infected from a CNA (which she could not name) and that his 4th right toe had turned to dark color. FM stated that CR#1 heels were bandaged and that is why the condition of them were not known for a few weeks. FM said CR#1 did not have a wound vac that he was supposed to have and that felt like that was because he started having issues with his insurance around August 2023. FM said that with all the staff turnover she could not recall all the names of the people spoken to on CR#1's behalf (but mostly nurses and aides). FM does not recall speaking with the Administrator. FM stated that around the beginning of August 2023, the family wanted to find another facility to have CR#1 transferred. FM said that it was difficult to find a facility that would take CR#1 because of all the wounds he had acquired while at the facility. FM said that his feet were wrapped most of time and do not recall boots being on his heels. Interview with LVN B on 9/25/2023 at 6:48 p.m., she stated that she started working at the facility March 2023. She stated that she did wound treatments for CR#1. She stated that she was not certified to complete wound care. She stated that CR#1 had wounds to his heels, sacral, upper back had a surgical wound, and she recalled the 1st right toe. She said that the heels were only getting betadine for awhile until they were debrided. She said that the worse wounds were the sacral area and the heels after the debridement. She stated that the facility administration expected her to provide wound care, pass medications, take vitals and weights, and overall patient care on halls 200 and 400 was hard because the residents on those halls had the highest acuity. She stated that she had a stroke several months ago and it forced her to recognize that she had been under a lot of stress working at the facility, which is why she resigned. She stated that she did not recall the exact treatments for every wound without access to PCC. Interview with the facility Physician on 9/26/2023 at 2:01pm, he stated that his NP provided a referral for Wound care Physician A to start treating CR#1 wounds when he was admitted . He stated that he was currently the facility physician and the MD. He said that he was aware of the wound on the right 4th toe and that at some point it had gotten better. He said that his wounds were cared for by the Wound care doctor. He stated that the Administrator made him aware that she terminated the services of Wound care physician A on or about 9/5/2023. He said that she did not say why she no longer wanted his services, and he did not ask. He said that he assessed CR#1 again to assume care until the administrator found another doctor on or about 9/6/2023. He stated that once he made a referral for wound care that physician would provide all the wound care services. He attempted to pull up CR#1's records on his phone. He said that it was a HIPAA violation to show his record, but that anytime he observed a new wound on CR#1 it was documented, and orders were placed as needed. He stated that he would send an e-fax and it would be directly uploaded into the facility's PCC system. He said that he was not aware of any issues with orders were not in the system. He was then made aware that no orders were found for CR#1's 4th right toe, and wounds on his left and right heels and sacrum were worse than when CR#1 was admitted . He said that he was made aware of the issues after wound care doctor A was terminated. Interview with Wound Care Physician B on 9/28/23 at 3:26pm, revealed him to state that on 9/15/23, he conducted an assessment on CR#1. He stated that from the current documentation from former Wound Care Physician A, the sacral wound was measured larger than the documentation showed and the wound on right foot (4th toe) was having purulent drainage and he did not see any documentation, multiple wounds for a complex patient, high risk with drainage was his reason for sending his to the hospital. He stated that he thought the most appropriate thing for him to do was send him to have advanced imaging and possible surgical evaluation. He said that it was appropriate to escalate care based on those issues. He stated that he consulted with the facility due to a referral by the facility physician on only residents that the facility wants him to consult. He said that he does not see all residents that have wounds in the facility. Post surgical wounds are usually handled by the facility doctor and he does not care for those same residents. Interview with hospital surgeon on 9/28/2023 at 5:07pm, he stated that he was a vascular surgeon. He stated that he performed the below knee amputations(BKA) of both of CR#1's left and right legs. He said that his pressure ulcers on the left and right heels were deep in the tissue and badly infected. He said the bone infection was very serious and amputating the limbs were the only option. He said that he maintained the knees so CR#1 could possibly use prosthetics in the future. He said that the wounds were not adequately cared for by the facility where CR#1 resided. He said that he could tell that there could not have been heel supports used to keep his heels from the bed and the facility staff probably did not reposition him as needed. He said that although the resident had peripheral vascular disease, his blood flow was not an issue. He stated that the SW had a statement in his chart to find alternate placement upon his discharge and he agreed. He said that he will need to go to a facility that will properly care for his wounds. An Immediate Jeopardy (IJ) situation was identified on 9/25/2023 at 2:03p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Immediate action taken: Resident #1 had been discharged to the hospital on 9/16/23 and had not returned to the facility at the time the immediate jeopardy was issued. Once resident #1 was seen by the wound care doctor on 9/16/23, an order to send to the ER for evaluation was given and implemented immediately. A facility audit of all residents to be completed by the Director of Nursing/Designee by 9/25/2023 of all residents to validate a skin check has been completed in the past 7 days and that any areas identified had been communicated to the physician. Any resident who has not had a documented skin check within the past 7 days had a skin check completed by Regional Nurse Consultant and/or DON on 9/25/2023. The facility reviewed/revised the system for receiving orders from the physician and communicating with the physician more efficiently and effectively. The facility created a plan of improvement to address changes including acceptable methods of communication, order transcription and use of order binder. Care plan audit for all residents with wounds to be completed on 9/26/23 by MDS coordinator and Regional MDS support to assure that the CP matches current wounds and interventions. Nursing administration to initiate acute care plans and IDT to monitor and assure that care plans are updated timely. In-services initiated 9/26/23 with administrative nursing team related to completion and updating of acute and chronic wound care plans Ad Hoc QAPI meeting completed with IDT, Regional Nurse Consultant and Medical Director on 9/26/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: Skin checks were completed by DON/designee on 9/25/23 including 100% of residents in the facility with no unknown wounds discovered. A facility wound audit was completed on 9/25/2023 to validate all wounds had current and appropriate treatment. Education was initiated for the facility nursing staff by Administrator/designee on 9/25/23 related to ensuring all resident's health and safety are protected from abuse and neglect*. Education was initiated for Nursing Assistants by DON/designee on 9/25/2023 on ensuring residents at high risk for skin breakdown are turned and repositioned at least every two hours, how to provide proper bathing/personal cares with residents with wounds, who to notify if skin breakdown is identified and using the Stop and Watch tool in POC to alert nurse*. Education was initiated for the DON by the Regional Nurse Consultant related to oversight of the wound care program on 9/25/23. Education to be initiated by DON/Designee on 9/25/2023 with all Licensed Nurses regarding changes in resident condition, the importance of completing a thorough weekly skin assessment, completing, and documenting wound care per physician orders, validating that all wounds have orders for treatment, reporting immediately when a resident has incurred a skin impairment notifying the doctor of new or worsening skin areas, and proper documentation*. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working 9/25/2023. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. Monitoring included: Record review of an in-service on 9/25/2023 revealed, Regional Nurse conducted oversight of wound care program, required documentation, interventions and follow-up with DON. All wounds must have care plans that indicate the location and etiology of each wound present. Interventions must be updated in a timely manner. Record review of an in-services on 9/25/2023, revealed Regional nurse covered stop and watch documentation of new alterations in skin integrity. Skin breakdown prevention, turning and repositioning residents at high risk of skin breakdown, change in condition, completing wound assessments, validating wound orders, reporting new wounds and documenting. Interviews were conducted between 9/26/2023-9/28/2023 with 3 CNA's, 4 LVN's, 2 RN's on day, evening and night shifts. They reported that they were in-serviced on observing wounds, documenting, stop and watch, reporting changes to physicians, accurate weekly assessments, abuse, neglect and exploitation as well as protocol for pressure wounds. They were able to verbalize their understanding of the in services provided. Subsequent interview with the Administrator on 9/28/2023 at 12:25pm, she stated that after all physician visits to the facility, they will leave a visit summary. The summaries will also be emailed and followed up by the DON. She said that their system will get better and so treatments were adequate and timely for residents. Subsequent interview with the DON on 9/28/2023 at 12:55pm, she stated that she was aware that it was her responsibility to ensure physician orders complete and that there was a care plan for wounds, treatments were conducted timely and without any missed treatments. She said that she was still new but will learn the system and work with staff to make the facility better. An Immediate Jeopardy (IJ) situation was identified on 9/25/2023 at 2:03 p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system.

Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents to include the quality and timeliness of services for 1 of 7 residents (CR#1) reviewed for ordered laboratory services. 1. The facility failed to obtain routine lab work for CR#1 on 02/08/22 and 02/24/22 per physician order. 2. The facility failed to obtain STAT lab work for CR#1 on 03/01/22 and 03/03/22 per physician order. An Immediate Jeopardy (IJ) situation was identified on 03/08/22 at 4:20 PM. While the IJ was removed on 03/11/22 at 2:50 PM, the facility remained out of compliance at a scope of an isolated with actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for untreated illnesses, delays in necessary care and deterioration in condition. Findings include: Record review of CR#1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1's Admission MDS, dated [DATE], revealed CR#1 did not have a BIMS. CR#1 was diagnosed with Urinary Tract Infection within the last 30 days and diabetes mellitus. CR#1 had an indwelling catheter for urinary continence. Record review of CR#1's Care Plan, dated 03/04/22, revealed CR#1 had a suprapubic catheter. Staff were to monitor, record and report to the physician signs and symptoms of infection of urinary tract infection, altered mental status, change in behavior and fever. CR#1 had diabetes mellitus with potential for abnormal blood sugars levels. Staff were to give medication as ordered by the physician. Staff were to monitor/document for side effect and effectiveness. Staff were to monitor for signs of [CONDITION(S)] and [CONDITION(S)]. Record review of CR#1's physician orders, dated 03/2022, revealed .CBC, CMP, HGA1C to be drawn on 2/8/22. There was no start date documented. Record review of CR#1's physician orders revealed no lab orders documented in the EMR for 02/24/22, 03/01/22, 03/02/22, and 03/03/22. Record review of CR#1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Written by PA. Record review of CR#1's Nurse Progress Notes revealed the following: Record review of nurse progress notes dated 3/01/2022 revealed Received n/o to obtain COVID-TEST for fever, collect cbc, bmp, UA w/culture STAT. Res in bed, writer gave PRN Tylenol to reduce fever, NP notified. Gave on coming nurse report. Written by LVN A. Record review of nurse progress notes dated 03/02/2022 at 2:04 AM revealed Covid-19 test as order was neg in house. Written by LVN B. Record review of nurse progress notes dated 03/02/2022 at 11:19 AM revealed This writer attempted to call [the laboratory] to set up profile in order to put in new orders. No success. Will try again later. Written by LVN C. Record review of nurse progress notes dated 03/02/2022 at 2:15 PM revealed [NP] informed about AMS. Repeated new orders to be obtain STAT. Orders for upcoming STAT orders ordered by writer. Written by LVN C. Record review of nurse progress notes dated 03/02/2022 at 3:26 PM revealed received n/o for STAT labs and UA with C&S. Family here and took resident out for awhile. Resident with suprapubic catheter and was clamped to obtain urine. No success obtained. Re-clamped catheter to obtain urine. Report given to oncoming nurse. Written by LVN C. Record review of CR#1's SBAR, dated 03/02/22, revealed CR#1 had an elevated temperature of 102.1 degrees Fahrenheit which started on 03/01/22. CR#1 had altered mental status, CR#1 was nauseous. Lab work was requested the NP was notified. Record review of progress notes dated 03/03/2022 revealed Pt transferred to [Hospital] at 0726 via EMS due to elevated temperature and blood sugar. Please see Change of Condition for full details. Cell phone and charger left the building with the patient. Written by LVN D. Interview with LVN C attempted on 03/04/22 at 2:27 PM and 03/07/22 at 4:47 PM were unsuccessful. Interview with LVN D attempted on 03/07/22 at 4:46 PM and 03/08/22 at 11:45 AM were unsuccessful. In a telephone interview on 03/04/22 at 6:03 PM, LVN A stated on 3/1/22 about 1:15 PM CR#1 had an elevated temperature, so she contacted the physician. CR#1 was given PRN Tylenol and STAT labs were ordered. LVN A said she had multiple orders to input into the system for different residents, so she asked for help. It was during shift change. LVN A reported she asked LVN B for help and he told LVN A he would put the lab orders in the system. The next day (03/02/22) the orders were not in the system and labs were not drawn. On 03/02/22 LVN A said she asked LVN C to help with CR#1's lab orders. LVN C did not put the orders into the system or draw the labs. On 03/02/22 during shift change LVN B told LVN A that he did not know how to put lab orders into the system. LVN B should have contacted management for help. CR#1 did not get her lab work done. LVN A said she should have stopped the other orders and completed CR#1's orders because they were STAT since they were more important. In an interview on 03/07/22 at 4:48 PM, LVN B stated he administered a COVID-19 test on CR#1 but he was not aware of any other orders or labs that needed to be completed. He did not recall LVN A asking for help with labs. In an interview on 03/04/22 at 1:55 PM, the ADON stated STAT orders were supposed to be completed within 4-6 hours. She was not aware LVN C had issues with CR#1's lab profile. The profile was already set up she just needed to input the information. If LVN B or LVN C had issues, then they should have asked for help. CR#1 was supposed to have lab work completed on 03/01/22 and 03/02/11. She was sent to the hospital on 3/3/22. The facility had all agency nursing staff so physician orders were not being input into the system or followed up on. The ADON stated she was the only person who was putting in orders and followed up on orders, she could not do everything herself. The DON was no longer at the facility. In a telephone interview on 03/07/22 at 4:14 PM, the NP stated routine labs were ordered for CR#1 on 2/24/22 but were not completed. On 03/01/22 STAT labs were ordered for CR#1 due to a change in condition due to elevated temperature. On 03/02/22 STAT labs were reordered due to orders not being completed on 03/01/22. CR#1 had altered mental status. On 03/03/22 she got a text from the ADON asking for a STAT lab order for CR#1 because labs were not drawn on 03/02/22. By 03/03/22 CR#1 had to be sent to the hospital because she was too sick to stay at the facility. CR#1 was diagnosed with [CONDITION(S)] at the hospital. CR#1 had to be very ill to still be in the hospital. The NP stated it was important the facility completed the lab orders for CR#1 because hospitalization could have been avoided and CR#1 would have been treated earlier. In a follow up interview on 03/08/22 at 12:41 PM, the NP stated CR#1 was supposed to have routine labs drawn on 02/08/22. Another order was given on 2/24/22 since it was not completed on 02/08/22. The labs were supposed to be drawn to get a baseline on the resident. In an interview on 03/07/22 at 5:15 PM, the Regional Nurse Consultant stated she spoke with LVN A about leaving her shift without completing the STAT lab orders. The STAT lab orders should have been completed and not passed down or delayed before she left. She read the notes regarding LVN C not being able to put CR#1's information into the lab system and complete the UA draw from her catheter. CR#1 went on an outing on 03/02/22 so her labs needed to be redrawn. The ADON was in the building on 03/02/22 and LVN C could have asked for help. The staff dropped the ball on CR#1's labs. CR#1 had STAT labs ordered due to fever. The ADON had been relieved of duty due to not following up on issues. LVN A and LVN C who were agency staff were no longer allowed to work at the facility due to the incident with CR#1. In an interview on 03/08/22 at 11:50 AM, the Regional Nurse Consultant stated none of the labs were completed that were ordered for CR#1 on 02/08/22 and 02/24/22. It was important for staff to follow the physician orders so residents could get the appropriate plan of care they needed. In an interview on 03/08/22 at 1:30 PM, the Regional Nurse Consultant stated she was not sure why the orders were not done, and labs not drawn for CR#1 on 02/08/22 and 02/24/22. The ADON and former DON dropped the ball. The orders were not put into the lab system to be drawn. When the lab orders were put into the lab system a technician came out to complete the labs. The nurses also did not put the physician's orders into point click care on 02/24/22, 03/01/22 and 03/02/22. The facility did not have a policy for STAT labs but did have a documented procedure the nurses were supposed to follow. An attempted follow up interview on 03/08/22 at 1:26 PM with the ADON was attempted and unsuccessful. Record review of CR#1's hospital records, dated 03/07/22, revealed she was admitted to the hospital for [CONDITION(S)], acute kidney injury on [CONDITION(S)] stage 4, [CONDITION(S)], acute [CONDITION(S)] bacteremia, catheter associated bacteriuria, [CONDITION(S)] bladder status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility policy Lab and Diagnostic Test Results - Clinical Protocol, dated 11/2018, revealed Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. Laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. This was determined to be an Immediate Jeopardy (IJ) on 03/08/22 at 4:20 PM. The Administrator and the DON were notified. The Administrator was provided with the Immediate Jeopardy template on 03/08/22 at 4:35 PM. The following Plan of Removal was submitted and accepted on 03/09/22 at 2:51 PM: PLAN OF REMOVAL Name of facility Date: 03/09/2022 Immediate Action: On 3/8/22, Nursing Administration conducted a 100% lab audit from 02/1/2022 to current to ensure all labs ordered had been verified and carried out. Physicians were notified of any issues identified. All results were reviewed in Ad Hoc QAPI with IDT Team 3/8/22. Analysis revealed that orders were not consistently being placed both in PCC & [Lab Company] Lab Portal; this along with lack of communication and high volume of Agency Staff lead to a breakdown of the Lab System. Facility Plan to ensure compliance quickly 1.Lab policy & procedure was reviewed by IDT Team 3/8/22 prior to initiating training for nursing staff. All licensed nurses currently on shift, including agency staff, were in-serviced by Regional Nurse Consultant/designee 3/8/22 on: o Lab Orders and Clinical Process for Lab and Diagnostic Test Results Policy and Procedure o Reviewing lab services o Stat lab orders; with turnaround time of 4-6 hrs after order has been entered and Time Specific Tests o [Lab Company] Web-station Use (Lab Portal) o Collecting and Labeling Specimen Samples o Laboratory Monitoring - Involves reviewing all of the following: Lab Book, 24Hr Report, and PCC Order Listing Report. The Administrative/IDT team will be monitoring all orders daily in the clinical meeting to ensure all new lab orders have been entered in PCC, placed in [Lab Company] Lab Book, & has a progress note with reason for the order. The labs from the previous day will be reviewed to ensure they were completed, MD was notified and documented along with any follow-up orders. o Physician Notification of lab results, follow-up or concerns - Nurses must contact the MD/NP immediately when a lab is unable to be drawn for any reason. We need to obtain new orders, interventions, monitoring, etc. as indicated. In addition to notification of the MD, nurses must notify the Administrator and the DON/designee. Regional Nurse Consultant/designee will continue to in-service all licensed nurses, including agency staff, prior to working an assigned shift. Administrator will ensure all required training has been completed. 2.AD-HOC QAPI completed on 03/08/2022. 3. Licensed Nurses, including agency staff, completed laboratory test to ensure comprehension of education provided on 3/8/22 4. All other licensed nurses, including agency staff, will be trained prior to the start of their shift on: o Lab Orders and Clinical Process for Lab and Diagnostic Test Results Policy and Procedure lab Orders o Reviewing lab services o Stat lab orders (4-6hrs) and Time Specific Tests (as scheduled) o [Lab Company] Web-station Use (Lab Portal) o Collecting and Labeling Specimen Samples o Laboratory Monitoring - The Administrative/IDT team will monitor all lab orders daily in the clinical meeting to ensure they have been entered in PCC and processed correctly through [Lab Company]. o Physician Notification of lab results, follow-up or concerns - Nurses must notify MD/NP immediately if lab order was unable to be carried out for any reason. In addition to notification of the MD, nurses must notify the Administrator and the DON/designee 5. The Administrative/IDT team will be monitoring all orders daily in the clinical meeting to ensure all lab orders have been entered in PCC and processed correctly through [Lab Company]. All labs drawn the previous day will be reviewed to ensure they were drawn, resulted, documented, and required notifications have been made. 6. Staff will not be able to work until they have been trained on the Lab Process by completing the following in-services: o Lab Orders and Clinical Process for Lab and Diagnostic Test Results Policy and Procedure o Reviewing lab services o Stat lab orders (4-6hrs) and Time Specific Tests (as scheduled) o [Lab Company] Web-station Use (Lab Portal) o Collecting and Labeling Specimen Samples o Laboratory Monitoring - The Administrative/IDT team will monitor all lab orders daily in the clinical meeting to ensure they have been entered in PCC and processed correctly through [Lab Company]. o Physician Notification of lab results, follow-up or concerns. Nurses must notify MD/NP immediately if lab order was unable to be carried out for any reason. In addition to notification of the MD, nurses must notify the Administrator and the DON/designee 7. All Processes will be in place by 3/9/22 State Surveyor Monitored the plan of removal as follows: Interviews were started on 03/10/22 at 1:15 PM and continued through 03/11/21 at 2:00 PM with 14 staff across all three shifts, including weekdays, weekends and multiple departments. The staff interviewed regarding the plan of removal were: LVN E, LVN F, LVN G, LVN H, LVN I, LVN J, LVN K, LVN L, Regional Nurse Consultant, Regional VP, RN A, Nurse Consultant, MDS Coordinator, Administrator in Training. All staff interviewed verbalized adequate understanding of the plan of removal training received. Plan of Removal Evidence Binder: Record review revealed Quality Assurance Committee QAPI Meeting completed on 03/08/22. Record review revealed Order Listing Report for Labs completed on 03/08/22. Record review revealed Daily Phlebotomy Collection Log reviewed completed on 03/8/22. Record review revealed Lab Report Result Reviews completed on 03/08/22. Record review revealed Lab Orders/Results for Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 revealed no concerns. Record review revealed Lab Monitoring Tool for lab orders dated 3/9/22. Record review revealed the Laboratory binder was located at the nurse station. Record review revealed the facility had electronic 24-hour report system. Record review revealed Laboratory Service Test completed by employees were dated 3/8/22 - 3/10/22. Record review revealed facility in-services on Lab Policy and Procedures were started on 03/08/22. The Administrator and the DON were informed the Immediate Jeopardy was removed on 03/11/22 at 2:50 PM. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents who require [CONDITION(S)] received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents (Resident #1) reviewed for [CONDITION(S)]. 1. The facility failed to ensure Resident #1, who was COVID-19 positive, received hemodialysis treatments as ordered by her physician until she missed two appointments and exhibited symptoms of fluid overload with altered mental status and swelling and required emergency medical care. 2. The facility failed to ensure their COVID-19 action plan provided protocols/procedures for COVID-19 positive residents who required outside services, such as [CONDITION(S)]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:43 p.m. While the IJ was removed on [DATE] at 12:10 p.m., the facility remained out of compliance at a scope of a isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed COVID-19 positive residents who required hemodialysis treatments at risk of missing vital treatments and experiencing worsening kidney damage, serious health side effects, and death. Findings included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with end-stage [CONDITION(S)] (stage 5 kidney disease), dependence on renal [CONDITION(S)] (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), [CONDITION(S)] (bacterial skin infection), [CONDITION(S)] (a long-term mental disorder) acquired absence of the right leg below the knee, chronic [CONDITION(S)] (infection that causes liver inflammation and damage) and diabetes. Resident #1 was discharged to an acute care hospital on [DATE] and returned to the facility on [DATE]. Record review of Resident #1's MDS, dated [DATE] revealed she had a BIMS score of 4 (severe cognitive impairment); she required extensive and total assistance from staff with bed mobility, transfers, ambulation via wheelchair, dressing, toilet use, personal hygiene and bathing; she was always incontinent of bowel and bladder; and she required [CONDITION(S)]. Record review of Resident #1's care plan, revised on [DATE] revealed she had an ADL self-care performance deficit due to impaired balance, limited mobility, and a right below-the-knee amputation; she had a communication problem due to confusion and forgetfulness and impaired cognitive function/dementia or thought processes due to forgetfulness and confusion; she was incontinent of bowel and bladder; she was on diuretic therapy; and she had renal insufficiency due to end stage kidney disease and required hemodialysis on Mondays, Wednesdays, and Fridays (Interventions/tasks included: Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds). Record review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Hemodialysis Every Monday, Wednesday, and Friday, Chair Time 4 p.m. Record review of Resident #1's progress notes for [DATE] and February 2022 revealed the following: On [DATE], at 4:39 p.m. LPN A wrote, Note Text: late entry: at approx. 2:00 p.m., Resident tested positive for covid, this nurse contacted [CONDITION(S)] center regarding covid policy regarding treatment, RN stated resident info sent to [CONDITION(S)] center covid team and they will contact facility regarding date and time for next [CONDITION(S)], instructed facility to send to ER if s/s of overload present before time and date scheduled with [CONDITION(S)] center Covid Facility, transport canceled at this time pending information from facility regarding protocol, resident remains asymptomatic at this time, resident changed and dressed and transferred to Covid hall without incident in stable condition, emergency contact contacted and informed of room change, covid result, and cancellation of [CONDITION(S)] with details about rescheduling and possible ER transport if s/s of overload presents, RP verbalized understanding. On [DATE], at 1:14 p.m., LVN B wrote, Late Entry: (This note was actually written on [DATE], at 1:31 p.m.) Note Text: Spoke to RN charge nurse from [CONDITION(S)] center about COVID protocol information for resident. He states that they are still planning accordingly and that the care team still needs to meet to discuss the appropriate protocol for their facility. N/o: if pt is showing s/s of fluid overload send patient to ED for [CONDITION(S)]. NP on board with plan of care and all orders in place. On [DATE], at 1:45 p.m., LVN B wrote, Late Entry: (This note was actually written on [DATE] at 1:47 p.m.) Note Text: NP notified of transferred to hospital for AMS, fever, and pale color. She transferred out via EMS on stretcher at approx. 6:50 p.m. On [DATE], at 4:00 p.m., LVN B wrote, Note Text: Spoke to charge nurse from [CONDITION(S)] center for follow up on plan for this COVID positive resident. He states that his team has not yet came up with a plan and if resident shows any symptoms of fluid overload to send patient to ED to get [CONDITION(S)]. NP is aware of this suggestion and is on board with the plan of care. On [DATE], at 5:23 p.m., LVN B wrote, Note Text: Spoke to [CONDITION(S)] center for plan of care for patient's appointment since she is positive for COVID. Appt is set for Thursday 1 p.m. Transportation will be with EMS transportation services. On [DATE], at 6:27 p.m., LVN B wrote, Note Text: Resident sent to ED per [CONDITION(S)] center orders. She is AMS at this time. Sent to ED for [CONDITION(S)]. On [DATE], at 1:51 p.m., LVN B completed the following SBAR Summary: SBAR Summary for Providers; Situation: The Change In Condition/s reported on this Evaluation are/were: Altered mental status Fever Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Tired, Weak, Confused, or Drowsy Change in skin color or condition At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: ,d+[DATE] - [DATE] 1:55 p.m. Position: Sitting r/arm - Pulse: 63 - [DATE] 9:35 a.m. Pulse Type: Regular - RR: 17 - [DATE] 1:55 p.m. - Temp: 98.3 - [DATE] 9:35 a.m. Route: Tympanic - Weight: 131.0 lb - [DATE] 11:30 a.m. Scale: - Pulse Oximetry: 97.0 % - [DATE] 1:07 a.m. Method: Room Air - Blood Glucose: 107 - [DATE] 1:55 p.m. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness Increased confusion (e.g. disorientation) - Functional Status Evaluation: General weakness - Abdominal/GI Status Evaluation: Decreased appetite/fluid intake Nursing observations, evaluation, and recommendations are: Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: NP B. New Testing Orders: C. New Intervention Orders: Record review of facility policy, titled, Policy/Procedure - Infection Prevention and Control, Subject: Novel Coronavirus Control Plan, revised on ,d+[DATE], revealed, . Managing residents with confirmed COVID-19 (Updated ,d+[DATE]): . The following interventions should be in place for residents with confirmed COVID-19 .Resident to remain in room except for medically necessary services. If they leave their room, they should wear a face mask . Initiate 911 to transfer residents in respiratory distress/unstable condition to an acute care hospital setting . Further review of the policy revealed no consideration, protocol, or procedure related to COVID-19 positive residents who required routine medical service outside the facility, such as [CONDITION(S)]. Record review of Resident #1's EMS records, dated [DATE] revealed 911 was called by the facility on [DATE] at 6:01 p.m. and the ambulance was dispatched at 6:04 p.m. The ambulance arrived at the facility at 6:16 p.m. and were with Resident #1 at 6:20 p.m. The ambulance left the facility with Resident #1 at 6:35 p.m. The report read in part, . 6:25 p.m.: blood pressure ,d+[DATE], pulse 114, 6:26 p.m.: pulse 111, respirations 32, oxygen saturation 92 .Medic dispatched emergency traffic for reports of a sick person. Upon arrival EMS observed an elderly female laying in bed, staring at the wall. The patient does not make eye contact but she does track EMS movement . The nurse on the scene states that the patient is COVID positive and has not been to her [CONDITION(S)] treatment since Thursday (her last [CONDITION(S)] treatment was Wednesday, [DATE]). The patient is typically alert and oriented x3. Upon arrival the patient was completely altered . EMS monitored vitals and assessments throughout transport. EMS obtained IV access and administered normal saline bolus. The patient was found to be febrile with a temperature of 101.4 degrees Fahrenheit. After approximately 5 minutes of receiving the fluid bolus, the patient began speaking. The patient stated that her belly hurt . The patients peri-umbilical area was rigid and tender to palpation . Record review of Resident #1's hospital records revealed she arrived in the ED at 6:58 p.m. A complete metabolic panel was ordered and collected on [DATE], at 8:55 p.m. The blood tests results were returned at 9:22 p.m. and included: BUN (a blood test which reveals important information about how well your kidneys are working) 47mg/dL (normal range: ,d+[DATE]) and creatinine (high levels in the blood indicate the kidneys are not functioning properly) 4.14 mg/dL (normal range .,d+[DATE].04). Resident #1 was admitted to the hospital at 11:38 p.m. The record read in part, . Patient baseline is demented but talking and bedbound, now only moans . Current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nephrology Consult Note, [DATE], 10:56 a.m Assessment and Plan: . Patient will receive [CONDITION(S)] at the end of the day due to COVID we cannot take patient to [CONDITION(S)] unit . Hemodialysis Nursing Note, [DATE], 7:48 p.m., Number of Hours: 3 hours and 40 minutes . Hospital Course . Patient was unresponsive in the ED but upon admission she became more responsive. Upon receiving hemodialysis and antibiotics patient's mentation and affect significantly improved . In a telephone interview with an EMT staff member on [DATE] at 9:15 a.m., she said EMS was called to the facility via 911 on [DATE] for a resident with fever, AMS, and no [CONDITION(S)] for 5 days. The EMT said upon assessment, Resident #1 looked pretty bad. She said Resident #1 was pale and just laid there with a blank stare. She said Resident #1 was awake, but she did not make any eye contact and she did not speak. She said Resident #1's vitals were abnormal with heart rate 110 (she said this was elevated as normal would be ,d+[DATE] at rest), respiratory rate was ,d+[DATE] (she said normal was 12 to 20), and her temperature was elevated at 101.4. The EMT said Resident #1 was given oxygen and an IV in the ambulance and after 5 min, she began to moan and said her belly hurt. She said that was the first time Resident #1 spoke but she was only able to say her name. The EMT said she observed Resident #1's abdomen was hard and tender. She said once they got to the hospital, Resident #1 started talking more. In an interview with the ADON on [DATE] at 10:45 a.m., she said when Resident #1 tested positive for COVID-19 on Friday, [DATE], the facility's nurses contacted the [CONDITION(S)] center so they could make arrangements because they did not know the center's COVID-19 protocol. She said Resident #1 usually went to [CONDITION(S)] on Mondays, Wednesdays, and Fridays at 5:00 p.m. She said the [CONDITION(S)] center staff said they did not have a COVID chair, so the nurses called the next day to follow up. The ADON said Resident #1 missed [CONDITION(S)] on Friday, [DATE], and Monday, [DATE], and was sent out to the hospital on Tuesday, [DATE]. She said the nurses assessed Resident #1 for symptoms of fluid overload over the weekend and she showed no symptoms of overload so the NP was ok with the plan to monitor the resident and wait to hear back from the [CONDITION(S)] center. On Monday, [DATE], LVN B called her about what the plan would be. The ADON said she left it to the DON to call the [CONDITION(S)] center but they never got back with them. The ADON said she did not speak to the NP but LVN B did. The ADON said Resident #1 was their first [CONDITION(S)] resident to be COVID-19 positive. She said they decided to send Resident #1 out to the emergency room when she missed two [CONDITION(S)] appointments and she experienced AMS and was pale in color. The ADON said some [CONDITION(S)] patients could miss two appointments and be fine, but others could miss one appointment and not be ok. She said they did not just send residents to the hospital without any symptoms, but they were not just waiting for Resident #1 to exhibit symptoms. She said they expected the [CONDITION(S)] center to come through and were told to monitor Resident #1 for symptoms of fluid overload. In an interview with LVN B on [DATE] at 11:55 a.m. she stated she was working in the COVID from 6 a.m. - 6 p.m. Monday through Friday. She said Resident #1 tested positive for COVID-19 on [DATE], before her chair time at the [CONDITION(S)] center. She said she called the [CONDITION(S)] center to tell them Resident #1 was positive and to ask what to do next and where to send her for [CONDITION(S)]. LVN B said the charge nurse at the [CONDITION(S)] center said he did not have an answer just yet but would get back with her. LVN B said her understanding was to call the [CONDITION(S)] clinic to notify them and to notify the NP, who gave orders. LVN B said the NP told her if Resident #1 showed symptoms of fluid overload to send her to the hospital and to call the [CONDITION(S)] center to let them know the resident tested positive. She said the NP wanted Resident #1 to go to [CONDITION(S)] that day or Saturday. LVN B said she was off that weekend and did not know what happened then. She said when she returned to work on Monday, [DATE] and saw Resident #1 had not gone to [CONDITION(S)], she called the [CONDITION(S)] center around 10 a.m. and the nurse said they did not know yet because he was still trying to talk to his boss for a plan. She said she did not know what the facility's action plan was for COVID-19 positive [CONDITION(S)] residents because they had never gone over that. LVN B said the DON and ADON told her to call the [CONDITION(S)] center to get plan of action. She said she called the [CONDITION(S)] center again on Tuesday ([DATE]) morning and they finally said to bring Resident #1 to [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays but she could not start until Thursday, [DATE]. On Tuesday evening, before she finished her shift, she observed Resident #1 with fever, AMS, and swelling. LVN B said since Resident #1 was showing symptoms of fluid overload, she sent her to the hospital. LVN B said she could not recall all of the symptoms of fluid overload, but she would find out. LVN B said she called the NP when she was sending Resident #1 out at 5:30 p.m. on [DATE]. She said she told the NP she was sending the resident out for fluid overload and [CONDITION(S)] and she agreed. LVN B said she had been in contact with the NP because she visited the facility daily and saw Resident #1 on Friday, [DATE] before Resident #1 tested positive and on Monday, [DATE], while Resident #1 was in the COVID-19 unit. LVN B said she assessed Resident #1 every two hours. She said normally, Resident #1 was intermittently alert and oriented x4 but she noticed when something was wrong with her, the resident started moving really slow, she answered questions really slow, and she looked really pale. LVN B said residents could go ,d+[DATE] days without [CONDITION(S)], so when she returned to work after the weekend, she wondered why the facility had not sent her out over weekend. She said she was instructed multiple times to wait and monitor for fluid overload but if she had been at the facility on the weekend, she would have sent Resident #1 out. LVN B said when she returned to work on Monday, [DATE], she did not think about sending her out to the hospital for [CONDITION(S)], but she should have. She said Resident #1 was still acting like herself and she was trying to figure out what the [CONDITION(S)] center was doing. LVN B said she knows she should have sent Resident #1 out. She said since then, the DON and the ADON both spoke to her said next time, she should send a resident to the emergency room if they missed [CONDITION(S)], so they do not have this problem again. She said Resident #1 was their first COVID-19 positive [CONDITION(S)] patient. In a telephone interview with the NP on [DATE] at 1:39 p.m., she stated one of the facility's nurses (she could not recall which nurse) contacted her on [DATE], at 2:00 p.m. and said Resident #1 had tested positive for COVID-19. The NP said she told the nurse to make sure she called the [CONDITION(S)] center right away because she knew they had special units for COVID-19 positive residents. She said she assumed things were fine and Resident #1 went to [CONDITION(S)] until someone called and told her Resident #1 had not been to [CONDITION(S)] and had been sent to the hospital with symptoms of fluid overload. She said she would not have been ok with Resident #1 missing [CONDITION(S)] all the way until Monday, [DATE], and she never wanted residents to miss any [CONDITION(S)] at all. She said Resident #1 was hemodynamically stable so she could have missed Friday, [DATE] and would have been ok but she would have needed [CONDITION(S)] on Monday, [DATE]. The NP said nobody from the facility called her over the weekend, so she was under the impression Resident #1 had gotten [CONDITION(S)]. The NP said she popped her head into Resident #1's room after that weekend (she could not recall what day this was because she did not do an actual assessment) and thought the resident was yelling a lot. She said she only glanced at her at that time and went about her day because she did not know anything was going on. The NP said her last official visit with Resident #1 was on [DATE]. The NP said she kept records of everything she ordered, and she never told facility staff she was ok with any plan for Resident #1 not to have [CONDITION(S)] or wait for her to exhibit symptoms. She said if anyone called her over the weekend, she would have notes but she did not have notes until the day Resident #1 was going out. She said LVN B called her and said Resident #1 had symptoms of fluid overload including shortness of breath and [CONDITION(S)]. She said she would have expected them to send Resident #1 out and not wait for signs and symptoms because some patients do not show signs before something serious happens or even death. In an interview with the DON on [DATE] at 2:30 p.m., she stated Resident #1 tested positive and was moved to the COVID unit. She said she did not know Resident #1 missed [CONDITION(S)] on Friday, [DATE] until Monday [DATE] when LVN B asked if the [CONDITION(S)] center was going to get the resident in since she missed an appointment. The DON said she called the [CONDITION(S)] center and was eventually informed they had changed Resident #1's chair time to Tuesdays, Thursdays, and Saturdays since she was COVID-19 positive. She said she asked the center staff if Resident #1 could go that day (this was on Tuesday, [DATE]) but they did not have an available chair. The DON said on [DATE], she told LVN B to monitor Resident #1 for fluid overload and send her to the hospital if she had symptoms. The DON said the longest she had ever known anybody to go without [CONDITION(S)] was ,d+[DATE] days, but it depended on how bad their kidneys were. The DON said she thought Resident #1 should have gone out on Monday, [DATE] because she had missed two appointments but there was a progress note which instructed them to wait and monitor. The DON said she did not call the NP because the progress note indicated the NP was aware and ok with the plan. She said Resident #1 could have experienced worsened kidney failure or death from not having [CONDITION(S)]. The DON said she was hired by the facility on [DATE] and they had never discussed having a protocol for COVID-19 positive residents who required [CONDITION(S)]. She said they only had two [CONDITION(S)] patients in the facility. Observation and interview of Resident #1 on [DATE] at 3:00 p.m. revealed she was laying in a low bed. Resident #1 said she had been living in the facility for two months and she liked it there. She said she went to [CONDITION(S)] on Mondays, Wednesdays, and Fridays but she had missed some days because of her foot. Resident #1 said she did not know why she went to the hospital recently. In a telephone interview with LVN C on [DATE], at 3:30 p.m. she said she worked in the facility's COVID-19 unit on Monday, [DATE], from 6 p.m. to 6 a.m. She said LVN B told her Resident #1 had to go to a COVID positive facility for [CONDITION(S)]. She said she saw a progress note that said the [CONDITION(S)] center ordered them to check the resident for s/sx of fluid overload. LVN C said she observed Resident #1 with +1 fluid/[CONDITION(S)] in her lower legs/ankles but her breathing and vital signs were good. She said she forgot to do a progress note for the fluid she found in Resident #1's ankles and she did not notify the NP because the [CONDITION(S)] was not that bad. LVN C said she knew she was supposed to send Resident #1 out for symptoms of fluid overload, but her [CONDITION(S)] was not that bad. In a telephone interview with LPN A on [DATE] at 11:06 a.m. she said she worked in the facility's COVID unit on [DATE] from 6 p.m. to 6 a.m. She said she worked a double and after 2 p.m. on [DATE], she moved over from the 100 Hall to the COVID unit. She said when Resident #1 tested positive, she called the NP to let her know and she told the NP she would call the [CONDITION(S)] center. She said the NP did not give any orders or ask for a follow up call. When she called the [CONDITION(S)] center, they called her back and said to watch for symptoms of overload. She said by this time, she was not yet on the COVID unit, so she just told the DON what the [CONDITION(S)] center said. LPN A said by Saturday, [DATE], the [CONDITION(S)] center had not called back. She went to Resident #1's room ,d+[DATE] times that night. LPN A said signs and symptoms of fluid overload would be [CONDITION(S)], lung sounds, increased blood pressure, any signs of swelling, and AMS but Resident #1 did not have any symptoms. She said she did not document any assessments or monitoring she did for Resident #1. She said the facility's corporate office called her the previous day ([DATE]) and got on to her about not making notes. She said LVN D worked behind her on [DATE]. She said she told LVN D Resident #1 had missed [CONDITION(S)] due to her COVID-19 status and they were waiting on correspondence from the [CONDITION(S)] center. In an interview with LVN D on [DATE] at 12:30 p.m., she stated she was not a permanent facility staff and was assigned to the facility by her agency. She said she worked whenever the facility needed her, usually 6 a.m. - 2 p.m. LVN D said she worked one shift on the COVID hall on Sunday, [DATE] from 6 a.m. - 6 p.m. (nurses worked 12 hour shifts on the COVID hall) She said when she arrived that day, she received report from LPN A, who was also an agency staff member. During report, they walked from room to room and LPN A said all the residents were good. LPN A told her Resident #1 no symptoms of fluid overload at that time. She said they routinely monitored [CONDITION(S)] residents for fluid overload. She said LPN a did not tell her Resident #1 missed any [CONDITION(S)] appointments and she did not tell her to monitor Resident #1 for any special reason. LVN D said when she and LPN A got to Resident #1's room, LPN A discussed normal stuff like, the resident was a [CONDITION(S)] patient and to watch for [CONDITION(S)] and fluid overload. LVN D said had she known Resident #1 missed [CONDITION(S)], she would not have treated her any different, but she would have noted things and she may have texted the NP to let her know what was happening. LVN D said she thought [CONDITION(S)] patients could go up to two days without [CONDITION(S)] and she would not send the resident out to hospital unless she had symptoms. LVN D said it was nursing knowledge to send a resident out with s/sx of fluid overload. She said if a [CONDITION(S)] patient missed one day and had pitting [CONDITION(S)] that was not severe she would contact the [CONDITION(S)] center for direction. She said +1 [CONDITION(S)] was not severe and she would not freak out on that but it would be enough to call the doctor if she had missed [CONDITION(S)]. LVN D said she may have been more aggressive on checking Resident #1. She said she checked Resident #1 every ,d+[DATE] minutes since there was not a lot of residents on the COVID hall. She said she looked at Resident #1's extremities each time she checked her but since she did not know about the situation, she did not make progress notes. In a telephone interview with LPN A on [DATE] at 6:15 p.m., she stated she did not know the [CONDITION(S)] center's COVID-19 protocol, so she called the center on [DATE], when Resident #1 tested positive. She said LVN B told her she would call the NP. LPN A said she entered her note about the call to the [CONDITION(S)] center late on Saturday night, ([DATE]) when she worked in the COVID unit. She said she did not have a reason to call the NP. The [CONDITION(S)] center staff told her he would get with the center's COVID-19 cohort team and he told her to watch Resident #1 for fluid overload and send her out if she had symptoms. She said she told LVN B what the [CONDITION(S)] center staff said. In a telephone interview with LVN B on [DATE], at 6:50 p.m., she stated when Resident #1 went to the COVID-19 unit, LPN A called the NP but she (LVN B) texted the NP a list of residents who were moved to the COVID-19 unit. The NP texted back to follow up with the [CONDITION(S)] center and tell them Resident #1 was COVID-19 positive. LVN B said she did recall speaking to the NP in person about Resident #1 missing [CONDITION(S)] and what the [CONDITION(S)] center told her when the NP visited the facility on Monday [DATE]. LVN B also said she told the NP she sent Resident #1 out to the hospital the day after she sent her out (LVN B sent Resident #1 out to the hospital on [DATE] but she told the NP on [DATE]). LVN B said she had been terminated by the facility and she thought it was weird the NP said she did not know Resident #1 missed appointments. She said she did recall telling the NP in person because that was why she wrote a note saying the NP was aware of what they were doing. In an interview with ADON on [DATE] at 11:13 a.m., she said LVN B was terminated because she lied about talking to the NP and that was what through everything off. She said she talked to the NP about the situation and found LVN B lied. She said the rest of the facility staff were following what LVN B said because they thought the NP was aware and told her monitor Resident #1. The ADON said she should have followed up but she believed what LVN B said the doctor said was true. She said Resident #1 could have died and it was only when Resident #1 was sent out that LVN B notified her and the other facility administration of any symptoms. The ADON said she did not Resident #1 did not have [CONDITION(S)] over the weekend. She said she asked every nurse how they checked Resident #1 for fluid overload, but nobody documented. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:43 p.m. The Administrator-In-Training, DON, ADON, and Regional Nurse Consultant were notified of the IJ. The Administrator and Administrator-In-Training were provided with the IJ template on [DATE] at 1:43 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 5:24 p.m.: PLAN OF REMOVAL Name of facility: Facility Date: [DATE] Immediate Action: Resident #1 received [CONDITION(S)] at ER [DATE], readmitted to the facility [DATE]; she has a COVID chair scheduled for [CONDITION(S)] Treatments on Tuesday, Thursdays, & Saturdays through [DATE], then she will return to her regularly scheduled days. This has been communicated to NP & verified today [DATE] by Administrator. All residents on [CONDITION(S)] were assessed [DATE] by facility Director of Nursing to ensure they were without any signs or symptoms of distress or fluid overload, and [CONDITION(S)] access sites are without signs or symptoms of infection, occlusion, or bleeding. All residents who are on [CONDITION(S)] were reviewed [DATE] by facility Director of Nursing to ensure orders are in place with current schedules and that each resident is receiving [CONDITION(S)] services per plan of care. Facility Plan to ensure compliance quickly Facility Nursing Staff provided education on [DATE] & has been Ongoing regarding: [CONDITION(S)] Report Sheets; including Pre & Post Vitals, Weights, Access Site Assessment, & Ensuring Appropriate Communication is Received on Return from [CONDITION(S)]; [CONDITION(S)] Communication Forms will be scanned into the Resident's Chart and Resident Grooming/Cares -by LVN/ADON Facility Nursing Staff provided education on [DATE] regarding: The Care of End Stage Renal Failure Residents - Change of Condition Policy - Guidelines for Notifying Physicians of Clinical Problems - Acute Condition Changes - Abuse & Neglect - [DATE] Notification of Physicians Any Time Orders Can Not Be Followed as Directed for Alternative Orders - by RN/DON The COVID-19 response plan was revised [DATE] by IDT Team of Administrator, DON, ADON, MDS, Regional Nurse, & Director of Clinical Services to include the following plan: If a resident who requires [CONDITION(S)] tests positive for COVID-19, the facility will notify the [CONDITION(S)] center of the positive test and identify if they are able to continue the routine schedule. If the [CONDITION(S)] center is unable to continue the [CONDITION(S)] schedule, the Director of Nursing/Designee will contact other [CONDITION(S)] centers and attempt to find alternative placement. If the facility is unable to arrange for [CONDITION(S)] schedule by the end of the next business day, the facility with communicate with the resident's attending physician/practitioner to notify of the interruption to the [CONDITION(S)] schedule. Orders for care will be obtained from the clinician and entered into the resident's medical record. Nursing staff will be educated about this protocol by [DATE] by DON or designee. The facility will reach out to other [CONDITION(S)] centers by [DATE] and identify who is able to provide emergent [CONDITION(S)] services. If a [CONDITION(S)] facility is identified who can provide this emergency service, the facility will initiate process of obtaining a contract with the facility. Agency Staff have a comprehensive compilation of the in-services conducted by the management staff. [DATE] It will be placed in a binder at the nurse's station to be reviewed & signed prior to the start of shift. Binder will be reviewed each morning during the Clinical Meeting by DON or designee for Compliance. Director of Nursing/designee will review documentation to ensure all changes of condition have been communicated to primary physician and Responsible Party each morning during the Clinical Meeting beginning [DATE]. Director of Nursing/designee will ensure all [CONDITION(S)] residents receive [CON

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one of ten residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1, who was COVID-19 positive, received hemodialysis treatments as ordered by her physician until she exhibited symptoms of fluid overload with altered mental status and swelling and required emergency medical care. 2. The facility failed to notify Resident #1's physician when she missed two [CONDITION(S)] treatments and was transferred to a local hospital for emergency medical care. 3. The facility failed to adequately monitor, assess, and document Resident #1's health status during the five days she went without hemodialysis treatments. 4. The facility failed to ensure their COVID-19 action plan provided protocols/procedures for COVID-19 positive residents who required outside services, such as [CONDITION(S)]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:43 p.m. While the IJ was removed on [DATE] at 12:10 p.m., the facility remained out of compliance at a scope of a isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed COVID-19 positive residents who required hemodialysis treatments at risk of missing vital treatments and experiencing worsening kidney damage, serious health side effects, and death. Findings included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with end-stage [CONDITION(S)] (stage 5 kidney disease), dependence on renal [CONDITION(S)] (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), [CONDITION(S)] (bacterial skin infection), [CONDITION(S)] (a long-term mental disorder) acquired absence of the right leg below the knee, chronic [CONDITION(S)] (infection that causes liver inflammation and damage) and diabetes. Resident #1 was discharged to an acute care hospital on [DATE] and returned to the facility on [DATE]. Record review of Resident #1's MDS, dated [DATE] revealed she had a BIMS score of 4 (severe cognitive impairment); she required extensive and total assistance from staff with bed mobility, transfers, ambulation via wheelchair, dressing, toilet use, personal hygiene and bathing; she was always incontinent of bowel and bladder; and she required [CONDITION(S)]. Record review of Resident #1's care plan, revised on [DATE] revealed she had an ADL self-care performance deficit due to impaired balance, limited mobility, and a right below-the-knee amputation; she had a communication problem due to confusion and forgetfulness and impaired cognitive function/dementia or thought processes due to forgetfulness and confusion; she was incontinent of bowel and bladder; she was on diuretic therapy; and she had renal insufficiency due to end stage kidney disease and required hemodialysis on Mondays, Wednesdays, and Fridays (Interventions/tasks included: Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds). Record review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Hemodialysis Every Monday, Wednesday, and Friday, Chair Time 4 p.m. Record review of Resident #1's progress notes for [DATE] and February 2022 revealed the following: On [DATE], at 4:39 p.m. LPN A wrote, Note Text: late entry: at approx. 2:00 p.m., Resident tested positive for covid, this nurse contacted [CONDITION(S)] center regarding covid policy regarding treatment, RN stated resident info sent to [CONDITION(S)] center covid team and they will contact facility regarding date and time for next [CONDITION(S)], instructed facility to send to ER if s/s of overload present before time and date scheduled with [CONDITION(S)] center Covid Facility, transport canceled at this time pending information from facility regarding protocol, resident remains asymptomatic at this time, resident changed and dressed and transferred to Covid hall without incident in stable condition, emergency contact contacted and informed of room change, covid result, and cancellation of [CONDITION(S)] with details about rescheduling and possible ER transport if s/s of overload presents, RP verbalized understanding. On [DATE], at 1:14 p.m., LVN B wrote, Late Entry: (This note was actually written on [DATE], at 1:31 p.m.) Note Text: Spoke to RN charge nurse from [CONDITION(S)] center about COVID protocol information for resident. He states that they are still planning accordingly and that the care team still needs to meet to discuss the appropriate protocol for their facility. N/o: if pt is showing s/s of fluid overload send patient to ED for [CONDITION(S)]. NP on board with plan of care and all orders in place. On [DATE], at 1:45 p.m., LVN B wrote, Late Entry: (This note was actually written on [DATE] at 1:47 p.m.) Note Text: NP notified of transferred to hospital for AMS, fever, and pale color. She transferred out via EMS on stretcher at approx. 6:50 p.m. On [DATE], at 4:00 p.m., LVN B wrote, Note Text: Spoke to charge nurse from [CONDITION(S)] center for follow up on plan for this COVID positive resident. He states that his team has not yet came up with a plan and if resident shows any symptoms of fluid overload to send patient to ED to get [CONDITION(S)]. NP is aware of this suggestion and is on board with the plan of care. On [DATE], at 5:23 p.m., LVN B wrote, Note Text: Spoke to [CONDITION(S)] center for plan of care for patient's appointment since she is positive for COVID. Appt is set for Thursday 1 p.m. Transportation will be with EMS transportation services. On [DATE], at 6:27 p.m., LVN B wrote, Note Text: Resident sent to ED per [CONDITION(S)] center orders. She is AMS at this time. Sent to ED for [CONDITION(S)]. Further review of Resident #1's progress notes for February 2022 revealed no documentation of assessments or monitoring of Resident #1 for signs and symptoms of fluid overload. Record review of an SBAR summary completed by LVN B on [DATE], at 1:51 p.m. read: SBAR Summary for Providers; Situation: The Change in Condition/s reported on this Evaluation are/were: Altered mental status Fever Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Tired, Weak, Confused, or Drowsy Change in skin color or condition At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: ,d+[DATE] - [DATE] 1:55 p.m. Position: Sitting r/arm - Pulse: 63 - [DATE] 9:35 a.m. Pulse Type: Regular - RR: 17 - [DATE] 1:55 p.m. - Temp: 98.3 - [DATE] 9:35 a.m. Route: Tympanic - Weight: 131.0 lb - [DATE] 11:30 a.m. Scale: - Pulse Oximetry: 97.0 % - [DATE] 1:07 a.m. Method: Room Air - Blood Glucose: 107 - [DATE] 1:55 p.m. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness Increased confusion (e.g. disorientation) - Functional Status Evaluation: General weakness - Abdominal/GI Status Evaluation: Decreased appetite/fluid intake Nursing observations, evaluation, and recommendations are: Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: NP B. New Testing Orders: C. New Intervention Orders: Record review of the facility policy, titled, Policy/Procedure - Infection Prevention and Control, Subject: Novel Coronavirus Control Plan, revised on ,d+[DATE], revealed, . Managing residents with confirmed COVID-19 (Updated ,d+[DATE]): . The following interventions should be in place for residents with confirmed COVID-19 .Resident to remain in room except for medically necessary services. If they leave their room, they should wear a face mask . Initiate 911 to transfer residents in respiratory distress/unstable condition to an acute care hospital setting . Further review of the policy revealed no consideration, protocol, or procedure related to COVID-19 positive residents who required routine medical service outside the facility, such as [CONDITION(S)]. Record review of Resident #1's EMS records, dated [DATE] revealed 911 was called by the facility on [DATE] at 6:01 p.m. and the ambulance was dispatched at 6:04 p.m. The ambulance arrived at the facility at 6:16 p.m. and were with Resident #1 at 6:20 p.m. The ambulance left the facility with Resident #1 at 6:35 p.m. The report read in part, . 6:25 p.m.: blood pressure ,d+[DATE], pulse 114, 6:26 p.m.: pulse 111, respirations 32, oxygen saturation 92 .Medic dispatched emergency traffic for reports of a sick person. Upon arrival EMS observed an elderly female laying in bed, staring at the wall. The patient does not make eye contact but she does track EMS movement . The nurse on the scene states that the patient is COVID positive and has not been to her [CONDITION(S)] treatment since Thursday (her last [CONDITION(S)] treatment was Wednesday, [DATE]). The patient is typically alert and oriented x3. Upon arrival the patient was completely altered . EMS monitored vitals and assessments throughout transport. EMS obtained IV access and administered normal saline bolus. The patient was found to be febrile with a temperature of 101.4 degrees Fahrenheit. After approximately 5 minutes of receiving the fluid bolus, the patient began speaking. The patient stated that her belly hurt . The patients peri-umbilical area was rigid and tender to palpation . Record review of Resident #1's hospital records revealed she arrived in the ED on [DATE] at 6:58 p.m. A complete metabolic panel was ordered and collected on [DATE], at 8:55 p.m. The blood tests results were returned at 9:22 p.m. and included: BUN (a blood test which reveals important information about how well your kidneys are working) 47mg/dL (normal range: ,d+[DATE]) and creatinine (high levels in the blood indicate the kidneys are not functioning properly) 4.14 mg/dL (normal range .,d+[DATE].04). Resident #1 was admitted to the hospital at 11:38 p.m. The record read in part, . Patient baseline is demented but talking and bedbound, now only moans . Current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nephrology Consult Note, [DATE], 10:56 a.m Assessment and Plan: . Patient will receive [CONDITION(S)] at the end of the day due to COVID we can not take patient to [CONDITION(S)] unit . Hemodialysis Nursing Note, [DATE], 7:48 p.m., Number of Hours: 3 hours and 40 minutes . Hospital Course . Patient was unresponsive in the ED but upon admission she became more responsive. Upon receiving hemodialysis and antibiotics patient's mentation and affect significantly improved . In a telephone interview with an EMT staff member on [DATE], at 9:15 a.m. she said EMS was called to the facility via 911 on [DATE] for a resident with fever, AMS, and no [CONDITION(S)] for 5 days. The EMT said upon assessment, Resident #1 looked pretty bad. She said Resident #1 was pale and just laid there with a blank stare. She said Resident #1 was awake, but she did not make any eye contact and she did not speak. She said Resident #1's vitals were abnormal with heart rate 110 (she said this was elevated as normal would be ,d+[DATE] at rest), respiratory rate was ,d+[DATE] (she said normal was 12 to 20), and her temperature was elevated at 101.4. The EMT said Resident #1 was given oxygen and an IV in the ambulance and after 5 min, she began to moan and said her belly hurt. She said that was the first time Resident #1 spoke, but she was only able to say her name. The EMT said she observed Resident #1's abdomen was hard and tender. She said once they got to the hospital, Resident #1 started talking more. In an interview with the ADON on [DATE], at 10:45 a.m., she said when Resident #1 tested positive for COVID-19 on Friday, [DATE], the facility's nurses contacted the [CONDITION(S)] center so they could make arrangements because they did not know the center's COVID-19 protocol. She said Resident #1 usually went to [CONDITION(S)] on Mondays, Wednesdays, and Fridays at 5:00 p.m. She said the [CONDITION(S)] center staff said they did not have a COVID chair, so the nurses called the next day to follow up. The ADON said Resident #1 missed [CONDITION(S)] on Friday, [DATE], and Monday, [DATE], and was sent out to the hospital on Tuesday, [DATE]. She said the nurses assessed Resident #1 for symptoms of fluid overload over the weekend and she showed no symptoms of overload, so the NP was ok with the plan to monitor the resident and wait to hear back from the [CONDITION(S)] center. On Monday, [DATE], LVN B called her (the ADON) about what the plan would be. The ADON said she left it to the DON to call the [CONDITION(S)] center, but they never got back with them. The ADON said she did not speak to the NP but LVN B did. The ADON said Resident #1 was their first [CONDITION(S)] resident to be COVID-19 positive. She said they decided to send Resident #1 out to the emergency room when she missed two [CONDITION(S)] appointments and she experienced AMS and was pale in color. The ADON said some [CONDITION(S)] patients could miss two appointments and be fine, but others could miss one appointment and not be ok. She said they did not just send residents to the hospital without any symptoms, but they were not just waiting for Resident #1 to exhibit symptoms. She said they expected the [CONDITION(S)] center to come through and were told to monitor Resident #1 for symptoms of fluid overload. In an interview with LVN B on [DATE], at 11:55 a.m., she stated she worked in the COVID unit from 6 a.m. - 6 p.m. Monday through Friday. She said Resident #1 tested positive for COVID-19 on [DATE], before her chair time at the [CONDITION(S)] center. She said she called the [CONDITION(S)] center to tell them Resident #1 was positive and to ask what to do next and where to send her for [CONDITION(S)]. LVN B said the charge nurse at the [CONDITION(S)] center said he did not have an answer just yet but would get back with her. LVN B said her understanding was to call the [CONDITION(S)] clinic to notify them and to notify the NP, who gave orders. LVN B said the NP told her if Resident #1 showed symptoms of fluid overload to send her to the hospital and to call the [CONDITION(S)] center to let them know the resident tested positive. She said the NP told her she wanted Resident #1 to go to [CONDITION(S)] that day or Saturday. LVN B said she was off that weekend and did not know what happened then. She said when she returned to work on Monday, [DATE] and saw Resident #1 had not gone to [CONDITION(S)], she called the [CONDITION(S)] center around 10 a.m. and the nurse said they did not know yet because he was still trying to talk to his boss for a plan. She said she did not know what the facility's action plan was for COVID-19 positive [CONDITION(S)] residents because they had never gone over that. LVN B said the DON and ADON told her to call the [CONDITION(S)] center to get plan of action. She said she called the [CONDITION(S)] center again on Tuesday ([DATE]) morning and they finally said to bring Resident #1 to [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays but she could not start until Thursday, [DATE]. On Tuesday evening, before she finished her shift, she observed Resident #1 with fever, AMS, and swelling. LVN B said since Resident #1 was showing symptoms of fluid overload, she sent her to the hospital. LVN B said she could not recall all of the symptoms of fluid overload, but she would find out. LVN B said she called the NP when she was sending Resident #1 out at 5:30 p.m. on [DATE]. She said she told the NP she was sending the resident out for fluid overload and [CONDITION(S)] and she agreed. LVN B said she had been in contact with the NP because she visited the facility daily and saw Resident #1 on Friday, [DATE] before Resident #1 tested positive and on Monday, [DATE], while Resident #1 was in the COVID-19 unit. LVN B said she assessed Resident #1 every two hours but did not document it. She said normally, Resident #1 was intermittently alert and oriented x4, but she noticed when something was wrong with her, the resident started moving really slow, she answered questions really slow, and she looked really pale. LVN B said residents could go ,d+[DATE] days without [CONDITION(S)], so when she returned to work after the weekend, she wondered why the facility had not sent her out over weekend. She said she was instructed multiple times to wait and monitor for fluid overload but if she had been at the facility on the weekend, she would have sent Resident #1 out. LVN B said when she returned to work on Monday, [DATE], she did not think about sending her out to the hospital for [CONDITION(S)], but she should have. She said Resident #1 was still acting like herself and she was trying to figure out what the [CONDITION(S)] center was doing. LVN B said she knew she should have sent Resident #1 out. She said since then, the DON and the ADON both spoke to her said next time, she should send a resident to the emergency room if they missed [CONDITION(S)], so they do not have this problem again. She said Resident #1 was their first COVID-19 positive [CONDITION(S)] patient. In a telephone interview with the NP on [DATE] at 1:39 p.m., she stated one of the facility's nurses (she could not recall which nurse) contacted her on [DATE] at 2:00 p.m. and said Resident #1 had tested positive for COVID-19. The NP said she told the nurse to make sure she called the [CONDITION(S)] center right away because she knew they had special units for COVID-19 positive residents. She said she assumed things were fine and Resident #1 went to [CONDITION(S)] until someone called and told her Resident #1 had not been to [CONDITION(S)] and had been sent to the hospital with symptoms of fluid overload. She said she would not have been ok with Resident #1 missing [CONDITION(S)] all the way until Monday, [DATE], and she never wanted residents to miss any [CONDITION(S)] at all. She said Resident #1 was hemodynamically stable so she could have missed Friday, [DATE] and would have been ok but she would have needed [CONDITION(S)] on Monday, [DATE]. The NP said nobody from the facility called her over the weekend, so she was under the impression Resident #1 had gotten [CONDITION(S)]. The NP said she popped her head into Resident #1's room after that weekend (she could not recall what day this was because she did not do an actual assessment) and thought the resident was yelling a lot. She said she only glanced at her at that time and went about her day because she did not know anything was going on. The NP said her last official visit with Resident #1 was on [DATE]. The NP said she kept records of everything she ordered, and she never told facility staff she was ok with any plan for Resident #1 not to have [CONDITION(S)] or wait for her to exhibit symptoms. She said if anyone called her over the weekend, she would have notes but she did not have notes until the day Resident #1 was going out. She said LVN B called her and said Resident #1 had symptoms of fluid overload including shortness of breath and [CONDITION(S)]. She said she would have expected them to send Resident #1 out and not wait for signs and symptoms because some patients do not show signs before something serious happens or even death. In an interview with the DON on [DATE] at 2:30 p.m., she stated Resident #1 tested positive and was moved to the COVID unit. She said she did not know Resident #1 missed [CONDITION(S)] on Friday, [DATE] until Monday [DATE] when LVN B asked if the [CONDITION(S)] center was going to get the resident in since she missed an appointment. The DON said she called the [CONDITION(S)] center and was eventually informed they had changed Resident #1's chair time to Tuesdays, Thursdays, and Saturdays since she was COVID-19 positive. She said she asked the center staff if Resident #1 could go that day (this was on Tuesday, [DATE]) but they did not have a chair available. The DON said on [DATE], she told LVN B to monitor Resident #1 for fluid overload and send her to the hospital if she had symptoms. The DON said the longest she had ever known anybody to go without [CONDITION(S)] was ,d+[DATE] days, but it depended on how bad their kidneys were. The DON said she thought Resident #1 should have gone out on Monday, [DATE] because she had missed two appointments but there was a progress note which instructed them to wait and monitor. The DON said she did not call the NP because the progress note indicated the NP was aware and ok with the plan. She said Resident #1 could have experienced worsened kidney failure or death from not having [CONDITION(S)]. The DON said she was hired by the facility on [DATE] and they had never discussed having a protocol for COVID-19 positive residents who required [CONDITION(S)]. She said they only had two [CONDITION(S)] patients in the facility. Observation and interview of Resident #1 on [DATE] at 3:00 p.m. revealed she was lying in a low bed. Resident #1 said she had been living in the facility for two months and she liked it there. She said she went to [CONDITION(S)] on Mondays, Wednesdays, and Fridays but she had missed some days because of her foot. Resident #1 said she did not know why she went to the hospital recently. In a telephone interview with LVN C on [DATE] at 3:30 p.m., she said she worked in the facility's COVID-19 unit on Monday, [DATE], from 6 p.m. to 6 a.m. She said LVN B told her Resident #1 had to go to a COVID positive facility for [CONDITION(S)]. She said she saw a progress note that said the [CONDITION(S)] center ordered them to check the resident for s/sx of fluid overload. LVN C said she observed Resident #1 with +1 fluid/[CONDITION(S)] in her lower legs/ankles but her breathing and vital signs were good. She said she forgot to do a progress note for the fluid she found in Resident #1's ankles and she did not notify the NP because the [CONDITION(S)] was not that bad. LVN C said she knew she was supposed to send Resident #1 out for symptoms of fluid overload, but her [CONDITION(S)] was not that bad. In a telephone interview with LPN A on [DATE] at 11:06 a.m., she said she worked in the facility's COVID unit on [DATE] from 6 p.m. to 6 a.m. She said she worked a double and after 2 p.m. on [DATE], she moved over from the 100 Hall to the COVID unit. She said when Resident #1 tested positive, she called the NP to let her know and she told the NP she would call the [CONDITION(S)] center. She said the NP did not give any orders or ask for a follow up call. When she called the [CONDITION(S)] center, they called her back and said to watch for symptoms of overload. She said by this time, she was not yet on the COVID unit, so she just told the DON what the [CONDITION(S)] center said. LPN A said by Saturday, [DATE], the [CONDITION(S)] center had not called back. She went to Resident #1's room ,d+[DATE] times that night. LPN A said signs and symptoms of fluid overload would be [CONDITION(S)], lung sounds, increased blood pressure, any signs of swelling, and AMS but Resident #1 did not have any symptoms. She said she did not document any assessments or monitoring she did for Resident #1. She said the facility's corporate office called her the previous day ([DATE]) and got on to her about not making notes. She said LVN D worked behind her on [DATE]. She said she told LVN D Resident #1 had missed [CONDITION(S)] due to her COVID-19 status and they were waiting on correspondence from the [CONDITION(S)] center. In an interview with LVN D on [DATE] at 12:30 p.m., she stated she was not a permanent facility staff and was assigned to the facility by her agency. She said she worked whenever the facility needed her, usually 6 a.m. - 2 p.m. LVN D said she worked one shift on the COVID hall on Sunday, [DATE] from 6 a.m. - 6 p.m. (nurses worked 12 hour shifts on the COVID hall) She said when she arrived that day, she received report from LPN A, who was also an agency staff member. During report, they walked from room to room and LPN A said all the residents were good. LPN A told her Resident #1 had no symptoms of fluid overload at that time. She said they routinely monitored [CONDITION(S)] residents for fluid overload. She said LPN A did not tell her Resident #1 missed any [CONDITION(S)] appointments and she did not tell her to monitor Resident #1 for any special reason. LVN D said when she and LPN A got to Resident #1's room, LPN A discussed normal stuff like, the resident was a [CONDITION(S)] patient and to watch for [CONDITION(S)] and fluid overload. LVN D said had she known Resident #1 missed [CONDITION(S)], she would not have treated her any different, but she would have noted things and she may have texted the NP to let her know what was happening. LVN D said she thought [CONDITION(S)] patients could go up to two days without [CONDITION(S)] and she would not send the resident out to hospital unless she had symptoms. LVN D said it was nursing knowledge to send a resident out with s/sx of fluid overload. She said if a [CONDITION(S)] patient missed one day and had pitting [CONDITION(S)] that was not severe, she would contact the [CONDITION(S)] center for direction. She said +1 [CONDITION(S)] was not severe and she would not freak out on that but it would be enough to call the doctor if she had missed [CONDITION(S)]. LVN D said she may have been more aggressive on checking Resident #1. She said she checked Resident #1 every ,d+[DATE] minutes since there was not a lot of residents on the COVID hall. She said she looked at Resident #1's extremities each time she checked her but since she did not know about the situation, she did not make progress notes. In a telephone interview with LPN A on [DATE] at 6:15 p.m., she stated she did not know the [CONDITION(S)] center's COVID-19 protocol, so she called the center on [DATE], when Resident #1 tested positive. She said LVN B told her she would call the NP. LPN A said she entered her note about the call to the [CONDITION(S)] center late on Saturday night, ([DATE]) when she worked in the COVID unit. She said she did not have a reason to call the NP. The [CONDITION(S)] center staff told her he would get with the center's COVID-19 cohort team and he told her to watch Resident #1 for fluid overload and send her out if she had symptoms. She said she told LVN B what the [CONDITION(S)] center staff said. In a telephone interview with LVN B on [DATE] at 6:50 p.m., she stated when Resident #1 went to the COVID-19 unit, LPN A called the NP but she (LVN B) texted the NP a list of residents who were moved to the COVID-19 unit. The NP texted back to follow up with the [CONDITION(S)] center and tell them Resident #1 was COVID-19 positive. LVN B said she did recall speaking to the NP in person about Resident #1 missing [CONDITION(S)] and what the [CONDITION(S)] center told her when the NP visited the facility on Monday [DATE]. LVN B also said she told the NP she sent Resident #1 out to the hospital the day after she sent her out (LVN B sent Resident #1 out to the hospital on [DATE] but she told the NP on [DATE]). LVN B said she had been terminated by the facility and she thought it was weird the NP said she did not know Resident #1 missed appointments. She said she did recall telling the NP in person because that was why she wrote a note saying the NP was aware of what they were doing. In an interview with ADON on [DATE] at 11:13 a.m., she said LVN B was terminated because she lied about talking to the NP and that was what threw everything off. She said she talked to the NP about the situation and found out LVN B lied. She said the rest of the facility staff were following what LVN B said because they thought the NP was aware and told her to monitor Resident #1. The ADON said she should have followed up, but she believed what LVN B said the doctor said was true. She said Resident #1 could have died and it was only when Resident #1 was sent out that LVN B notified her and the other facility administration of any symptoms. The ADON said she did not know Resident #1 did not have [CONDITION(S)] over the weekend. She said she asked every nurse how they checked Resident #1 for fluid overload, but nobody documented. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:43 p.m. The Administrator-In-Training, DON, ADON, and Regional Nurse Consultant were notified of the IJ. The Administrator and Administrator-In-Training were provided with the IJ template on [DATE] at 1:43 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 5:24 p.m.: PLAN OF REMOVAL Name of facility: Facility Date: [DATE] Immediate Action: Resident #1 received [CONDITION(S)] at ER [DATE], readmitted to the facility [DATE]; she has a COVID chair scheduled for [CONDITION(S)] Treatments on Tuesday, Thursdays, & Saturdays through [DATE], then she will return to her regularly scheduled days. This has been communicated to NP & verified today [DATE] by Administrator. All residents on [CONDITION(S)] were assessed [DATE] by facility Director of Nursing to ensure they were without any signs or symptoms of distress or fluid overload, and [CONDITION(S)] access sites are without signs or symptoms of infection, occlusion, or bleeding. All residents who are on [CONDITION(S)] were reviewed [DATE] by facility Director of Nursing to ensure orders are in place with current schedules and that each resident is receiving [CONDITION(S)] services per plan of care. Facility Plan to ensure compliance quickly Facility Nursing Staff provided education on [DATE] & has been Ongoing regarding: [CONDITION(S)] Report Sheets; including Pre & Post Vitals, Weights, Access Site Assessment, & Ensuring Appropriate Communication is Received on Return from [CONDITION(S)]; [CONDITION(S)] Communication Forms will be scanned into the Resident's Chart and Resident Grooming/Cares -by LVN/ADON Facility Nursing Staff provided education on [DATE] regarding: The Care of End Stage Renal Failure Residents - Change of Condition Policy - Guidelines for Notifying Physicians of Clinical Problems - Acute Condition Changes - Abuse & Neglect - [DATE] Notification of Physicians Any Time Orders Can Not Be Followed as Directed for Alternative Orders - by RN/DON The COVID-19 response plan was revised [DATE] by IDT Team of Administrator, DON, ADON, MDS, Regional Nurse, & Director of Clinical Services to include the following plan: If a resident who requires [CONDITION(S)] tests positive for COVID-19, the facility will notify the [CONDITION(S)] center of the positive test and identify if they are able to continue the routine schedule. If the [CONDITION(S)] center is unable to continue the [CONDITION(S)] schedule, the Director of Nursing/Designee will contact other [CONDITION(S)] centers and attempt to find alternative placement. If the facility is unable to arrange for [CONDITION(S)] schedule by the end of the next business day, the facility with communicate with the resident's attending physician/practitioner to notify of the interruption to the [CONDITION(S)] schedule. Orders for care will be obtained from the clinician and entered into the resident's medical record. Nursing staff will be educated about this protocol by [DATE] by DON or designee. The facility will reach out to other [CONDITION(S)] centers by [DATE] and identify who is able to provide emergent [CONDITION(S)] services. If a [CONDITION(S)] facility is identified who can provide this emergency service, the facility will initiate process of obtaining a contract with the facility. Agency Staff have a comprehensive compilation of the in-service

Based on observation, interview, and record review, the facility failed to ensure residents have the right to be free from abuse, neglect and exploitation for 3 of 6 residents (Residents #1, #2 and CR #1) reviewed for abuse in that: CR #1 sexually abused Residents #1 and #2 by kissing and/or touching their genitals. Resident #2 was angry and embarrased after the incident, and after assessment, the psychologist recommended short-term psychological services. The facility failed to address CR #1's inappropriate sexual behaviors. The facility failed to immediately implement safeguards and investigate to prevent further abuse when Resident #1 reported CR #1 sexually abused her. This failure could affect all residents and placed them at risk of unwanted sexual advances, abuse, mistreatment and neglect. Findings included: CR #1 Record review of CR #1's face-sheet revealed a [AGE] year old male initially admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE]. CR #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment. Further review revealed CR #1 required supervision for bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and personal hygiene. Record review of CR #1's departmental notes dated 9/15/20 revealed .Resident informed of medication regiment and verbalized food understanding. He has been NPO since midnight. Resident leaving facility in w/c . No distress noted. Being discharged home. Record review did not reveal why CR#1 was being discharged to home. On 9/17/20 Surveyor requested a copy of CR#1's care-plan, from the facility's Administrator, but one was not provided at time of exit. In an interview with RN#1 on 9/18/2020 at 1:48 PM, RN#1 stated in the past she overheard a couple of female residents get upset when CR #1 would get close to them, but she never asked the residents why they were upset nor did she report it to anyone. In an interview with CNA #1 on 9/18/2020 at 2:05 PM, CNA stated she observed CR #1 being physically inappropriate with female staff and would grab staff legs. CNA #1 further stated she reported CR #1's inappropriate behavior to LVN #1, and the LVN told CR#1 not to touch the staff. Resident #2 Record review of Resident #2's face-sheet revealed a [AGE] year old female initially admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS dated [DATE] revealed short and long term memory problems, and cognitive skills for daily decision making were severely impaired. Further review revealed Resident was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of facility's incident investigation dated 9/13/2020 revealed in part .date and time of incident: 9/13/20 at 1:51PM .It was reported to this writer, the facility administrator that [CR#1] was in [Resident #2's] room standing over her. He was kissing her and had his hand under the cover in her vagina area. Immediate Actions taken: [CR#1] was immediately removed from the room. Resident #2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 was placed under supervision. Name of witness: LVN #2. Record review of Resident #2's clinical record revealed a psychologist's progress note dated 9/15/2020, and revealed in part .Patient previously on caseload. Saw today at request of social worker. On 9/13/20, nursing note indicated other resident leaning over her and kissing her on the mouth with his hand under the blanket. Patient had reported he touched my vagina, this is not the first time. I attempted to discuss situation with patient today. Her responses were often difficult to understand. When I asked if a man had done something to her, When I told her the man was no longer at the facility, she said Thank you. When asked if she felt safe now, resident stated YES. Discussed with social worker and recommended a referral for what will most likely be short-term Psychological services . In an interview with Resident #3 on 9/18/2020 at 2:30 PM, Resident #3 stated that on 9/13/2020 he saw CR #1 in Resident #2's room standing over her bed, and about an hour later a nurse went into Resident #2's room and removed CR#1. In an interview with LVN #2 on 9/17/20 at 11:16 AM, LVN #2 stated on the day of the incident, she was walking down the hall when she saw CR #1 in Resident #2's room, standing by the bed, with his face over her face, and his hand under the covers below the waist. LVN #2 stated CR #1 was kissing Resident #2 on the mouth, she then proceeded to remove CR #1 from the room, and took him back to his room along with a one on one CNA who remained with him for the remainder of the shift. LVN #2 stated when she talked to Resident #2, the resident informed her that CR #1 kissed her and touched her vagina, and it had happened a lot in the past with CR #1. LVN #2 explained that she did not ask Resident #2 if she told anyone about the previous incidents, but a CNA later informed her that CR #1 would often go into Resident #2's room. LVN#2 stated Resident #2 did not express anger or fear to her. In an interview with facility's Administrator on 9/17/2020 at 11:50 AM, the Administrator stated on the day of the incident, she received a phone call from the facility informing her of the incident, and she immediately came to the facility and initiated an investigation. The Administrator stated CR #1 was placed on one on one supervision, and in her interview with CR #1, he admitted to kissing Resident #2, but denied touching her, and also stated Resident #2 was not angry.CR #1's Responsible party was notified of the incident, and he remained at the facility with one on one supervision until he was discharged to home with his family on 9/15/2020. Administrator stated she interviewed Resident #2, and the resident stated CR #1 kissed her on the mouth with his tongue, and touched her vagina with his finger but did not penetrate her. Resident #2 further expressed that the incident made her very angry, but that it was not the first time it happened, she never told anyone because she felt embarrassed. The administrator further stated that an abuse and neglect training was initiated for all facility staff post incident. Observation and interview of Resident #2 on 9/17/2020 at 12:05 PM, revealed Resident lying in bed, dressed and groomed appropriately. She had a flat affect. Resident #2 stated a male resident kissed her on the mouth with his tongue and touched her vagina which made her feel very angry because she did not want it to happen. Resident further stated it had happened before, but she did not tell anyone about it. Resident #1 Record review of Resident #1's face-sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's annual MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed Resident #1 required extensive assist of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. In an interview with LVN #1 on 9/18/2020 at 2:42 PM, LVN #1 stated on one occasion she overheard Resident #1 tell CR #1 to not touch her. LVN #1 also stated Resident #1 told her about CR #1 touching her, but she did not ask Resident #1 in what way CR#1 touched her. LVN#1 stated she made the facility DON aware of the incident. Observation and interview with Resident #1 on 9/18/2020 at 2:50 PM revealed Resident sitting in a wheelchair, groomed and dressed appropriately. Resident #1 stated CR#1 came into her room on one occasion and kissed her on the mouth. Resident #1 further stated she told CR #1 to stop, and that she was not interested, and proceeded to tell LVN#1 about the incident. Resident #1 unable to recall exactly when the incident occurred, but stated it upset her because she wasn't interested in him, and she made him know she was not interested. In an interview with the DON on 9/18/2020 at 3:05 PM, the DON stated no one told her about CR #1 being inappropriate with Resident #1. In an interview with the facility Administrator on 9/18/2020 at 3:23 PM, the Administrator stated she was not made aware of an incident with CR#1 and Resident #1. Record review of Resident #1's nurse's notes from July 2020 through September 2020 revealed no documentation of CR #1 or unwanted contact. Record review of facility's undated policy titled Abuse, Neglect And Misappropriation of Property Prohibition revealed in part .The facility will ensure a safe environment for residents by prohibiting abuse, neglect and misappropriation of resident property with mechanism for reporting, investigating and protecting residents from actual or potential harm . Further review revealed .Definitions: Sexual Abuse: includes but is not limited to any unnecessary touching, or exposure of the resident's breast or any part of the genitals without voluntary, informed consent . Further review revealed .Training: E: Staff responsibility to immediately report any violation or alleged violations. F: Measures to be taken to protect the resident . Further review revealed .Prevention: 3: Residents identified as exhibiting abusive behaviors will be assessed and appropriate interventions included in the plan of care. 4: The Facility staff will immediately report and protect the resident if an allegation or observation of abuse has occurred .