Every finding on record at Golfcrest Nursing and Rehabilitation

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments for one (Nurse Cart for 200 Hall) of three medication carts reviewed for storage of medications. The Nurse Cart for 200 Hall had a one (1) Liter (L) bottle of Jevity 1.5 calorie, (a prescription liquid nutritional food), left unattended on top of the cart. This failure could place all residents at risk of adverse reactions to medications, drug diversion and spillage. In an observation on 07/14/2026 at 8:15 AM, a 1L bottle of Jevity 1.5 calorie, a prescription liquid nutritional food for administration into gastrotomy tube (a tube placed into the stomach for supplemental feeding) was left unattended by the 200 hall nursing station, where residents have the availability to access the medications cart. In an interview on 07/14/2026 at 8:16 AM, LVN A stated she was only gone for a second, she stated the nutritional supplement should not have been left on the cart unattended. LVN A stated all medications are to be in locked compartments per the facility policy. LVN A stated leaving medications unattended could result in potential resident injury with adverse effects and possible spillage. In an interview on 07/14/2026 at 9:00 AM, the DON stated the nurse in charge of the medication cart should ensure all medications were locked in the medication cart. The DON stated her expectations are that all medications are locked and never left unattended as this is a danger to all residents. The DON stated the possible dangers are adverse effects of taking medication that is not ordered for the resident and spillage. The DON stated it was the nurse's responsibility to maintain all medications in locked medication carts. In an interview on 07/14/2026 at 1:30 PM, the Administrator stated all medications should always be locked. The Administrator stated that all medications are always locked to prevent possible adverse effects of a resident taking a medication that is not prescribed for them and spillage. Record review of the facility policy for Medication Storage, dated February 2023 read in part: .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility was free of pests on two of three halls (Hall 100 and Hall 200) reviewed for pest control. The facility failed to ensure that resident's rooms were free of roaches, flies and gnats. This failure could place residents at risk of infection, skin irritation, allergies, and unsanitary living conditions which could result in a decline in their health and well-being. Observation during the survey process on 1/15/2025 between 11:30am and 2:00 pm revealed the following:room [ROOM NUMBER] had dead flies in resident's room, flies and gnats were observed in the bathroom.room [ROOM NUMBER] a live fly was noted on the resident's forehead.room [ROOM NUMBER] and 217, dead roaches were noted on the floor.room [ROOM NUMBER] flies were flying in the room, and live gnats were noted in bathroom. room [ROOM NUMBER] dead roaches were noted on the floor and live roaches crawling on the floor. Interview on 1/15/2026 between 11:30 and 2:00pm with 5 unidentified residents revealed that flies, gnats, and roaches were always in their rooms. They said the pest control company came to the building and treated pests, but the flies, gnats and roaches still come back. In an interview on 1/15/2026 at 1:30pm with Assistant Maintenance H, he said the pest control company was in the facility a few days prior to the survey. He said they were treating for roaches, gnats, flies and ants. He said they usually do morning walks through the building, check the maintenance log and talk to residents. He said depending on what was documented and concerns voiced by residents and staff, they tried to address the concerns immediately. In an interview on 1/20/2025 at 3:00pm with Maintenance Supervisor he said he usually does morning walks the building on Tuesday, Wednesday, Thursday and Friday. He said whatever concerns there was he would address them. He said he usually fixed what needed to be fixed. He said that he had a fly wipe which decreased the flies, and it seemed to be working. In an interview with the Administrator on 1/20/2026 at 5:00pm he said they were working on addressing issues and concerns brought to the facility. He said they were having pest control coming to the building once a month and the increased the visit from once a month to twice a month and he had seen improvement where roaches and flies were concerned. Record review of the pest control receipt dated 11/13/2025 revealed the pest control company was in the building on 11/25/2025, 12/11/2025, 12/23/2025 and 01/08/2026 to treat gnats, roaches, and ants. They treated patient rooms and guest rooms for roaches, gnats and ants and on 08/01/25. Further record review revealed the rooms that were identified with roaches and gnats were not included on the list of rooms that were treated on 01/08/2026. Record review of the undated pest control policy and procedures read in part .Policy Statement:Our facility shall maintain an effective pest control program.1. This facility has an ongoing pest control program to ensure that the building is kept free of insect and rodent.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and public on 2 of 3 Halls (100 and 200 Halls) reviewed for environmental concerns in that. 1. Overhead light was not illuminating in the overbed light of room [ROOM NUMBER].2. Baseboard coming off the wall in rooms 107, 1094. Peeling paint on the walls in rooms [ROOM NUMBERS]. 5. Bedroom and with trash, dust and food on the floor in room [ROOM NUMBER], 205, 105.6. Bathroom in 107 had dirty bathtub, broken sheetrock and dirty shower chair.7. Resident's feeding pump, air mattress and pump and O2 concentrator were not cleaned. 8. Electric outlet not covered in room [ROOM NUMBER]. Broken blinds, night stand stripping to the front This deficient practice could affect residents who resided in rooms on hall 100 and hall 200 by causing the residents to live in an environment that would not improve their quality of life. Findings included: Observation on 1/15/2026 between 11:00pm and 2:00pm revealed the following:room [ROOM NUMBER]'s baseboard not affixed to the wall. In the bathroom of 107 were the following:Broken sheetrock at the base of the shower pipe. In the shower tub was a dirty shower chair, disposable brief, wet tissue paper and a box with gloves. The strips in the bathtub were black and the bathtub had an accumulation of dust and dirt. room [ROOM NUMBER]'s baseboard was not affixed to the wall between Bed A and Bed B. The bed sheet on Bed A was worn and had brown stains on it. The silver tape that was affixed to the window was torn and the window had black stuff on it. The overbed light did not illuminate when turned on. room [ROOM NUMBER]'s nightstand had peeling strips on it. There were broken blinds in the hallway between hall 100 and hall 200. In room [ROOM NUMBER] the baseboard was not affixed to the wall.room [ROOM NUMBER] had no covering on the electrical outlet between Bed A and Bed B. room [ROOM NUMBER] had peeling paint behind Bed A.room [ROOM NUMBER] had trash, dirty gloves, dust, food crumbs and dirt on the floor.room [ROOM NUMBER]'s nightstand had peeling strips on the front were the drawers were located. Observation on 1/20/2026 between 12:45 and 4:00pm revealed the following:Room's 105, 107, 109 had antennas and cords on the floor. room [ROOM NUMBER] had an accumulation of black looking stuff in the corner under the window. Baseboard was not affixed to the wall in the bathroom.room [ROOM NUMBER] had an electric cord on the floor and peeling paint behind the bed. room [ROOM NUMBER]'s floor was dirty - stained floor with trash on the floor, soiled privacy curtains with dark dry substance on it.room [ROOM NUMBER], G-Tube feeding pole was soiled with copious amounts of dried beige substance that appeared to be the same color of the enteral feeding inside the bag hanging on the pole at the resident's bedside with formula on it. The Air mattress had stains on it and the pump hanging at the foot of the bed of the residents' air mattress was soiled with dried dark brown drips and dried beige streaks and drips of unknown substance down the sides and front of the pump. The O2 concentrator at the bedside had drips of dried beige substance down the sides and back of the machine. room [ROOM NUMBER] had dirty floor with trash containers filled and overflowing with trash. In an interview on 1/15/2026 at 1:05pm, Medication Aide F said she was going to look at the room. She looked at the room and said it was dirty, but she did not know if the room was cleaned that morning. She said she was going to get housekeeping to take care of it. In an interview on 1/15/2026b at 1:10am the Housekeeping Manager said he has 3 housekeepers and 1 floor tech. He said the floor tech cleans the hallways and the housekeepers clean the rooms. He said they usually start cleaning at 7am and when breakfast trays were served, they would check rooms to see which room needed to be cleaned first. He said he did not know why room [ROOM NUMBER] was not one of the first rooms to be cleaned. At that point he said he was going to clean the room. In an interview on 1/20/2025 at 3:00pm with Maintenance Supervisor, he said he usually does morning walks on Tuesday, Wednesday, Thursday and Friday. He said whatever concerns he got during his wall throughs and the log at the nurse's station; he tried to address them immediately. He said that he had a fly wipe which decreased the number of flies, and it was working properly. He said he was going to secure the cable wires that were on the floor from the cable boards to the wall because they were accident hazards. He said he was going to ensure the issues with food in resident's rooms were addressed to prevent the roaches, flies, gnats and ants. He said he was going to replace the missing socket cover in room [ROOM NUMBER]. He said they have a painting project they were working on, and he had done room [ROOM NUMBER]. He said there should be no bathtub in room [ROOM NUMBER] and he was going to address the issue of the dirty shower chair, dirty brief, wet tissues, a box with gloves and the broken sheetrock around the pipe. In an interview on 1/20/2026 at 5:00pm with the Administrator he said that he was going to address the environmental issues. He said he was working on a painting project, and they had completed one room. He said the light in 109 was fixed. Record review of the facility's undated policy and procedures titled Environment read in part:Policy StatementResidents are provided with a safe, clean, and homelike environment and encouraged to use their personal belongings to the extent possible.Policy Interpretation and Implementation1. Staff provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. clean and sanitary environment.b. comfortable (minimum glare) yet adequate (suitable to the task) lighting.d. clean bed and bath linens that are in good condition.e. pleasant, neutral scents.g. comfortable and safe temperatures (71 F - 81 F); andh. comfortable sound levels.3. The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include:a. overhead paging.b. institutional odors.c. institutional signage (for example, labeled storage closets and work rooms in common areas); and4. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes:a. sufficient general lighting in resident-use areas.b. task lighting as needed.c. reduction in glare (through use of light filters, no wax floors)e. maximum use of daylight.f. night lighting to promote safety and independence.

Based on observation, record review and interviews, the facility failed to ensure that resident's care plan was reviewed and revised by the interdisciplinary team to address 1 of 6 residents ( Resident #1's) behavior of refusing care in that:The facility failed to ensure that Resident #1's care plan was revised to address his refusal of showers.This failure could place residents at risk of not getting the care and services needed to improve their quality of life. Findings Included Record review of Resident #1's admission face sheet dated 1/15/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), diabetes (high blood sugar), Alzheimer disease (a progressive brain disorder causing memory loss), anxiety (excessive fear or worry), depression (mood disorder causing sadness), malnutrition(it is a condition where the body in not getting enough of the right foods) and diaper dermatitis (over hydration of the skin that looks like inflamed skin on the buttocks). Record review of Resident #1's quarterly MDS dated [DATE] revealed for Section C500 the resident's BIMS score was 11 indicating the resident was moderately impaired for decision making, For Section E: Behavior: The resident was coded as having no behaviors For Section GG: ADL's were coded for Eating as needing set up only, Oral hygiene he was coded as needing supervision, For toileting and lower body dressing he was coded as dependent on staff with 2 persons assist, For upper body dressing, shower/bath, putting on and taking off foot wear and personal hygiene he needed maximal assist from staff. For Bowel and Bladder, he was coded incontinent of bladder and as having a colostomy. Observation on 1/15/2026 at 1:50pm of Resident #1 revealed he was up in bed. He was alert and oriented and could make his needs known. He was groomed with no lingering odor. In an interview on 1/15/2026 at 1:50pm with Resident #1 regarding the care and services he received he said he had problems getting a shower. He said they usually gave him a bed bath, and he wanted a shower where they could soap him up and wash him off and they couldn't do that in the bed. Record review of Resident #1's progress notes and shower sheets revealed multiple documentation where the resident refused a shower and would rather take a bed bath instead. Review of shower sheets revealed the following dated the resident refused shower and requested baths were 1/5/2026, 1/6/2026, 1/8/2026, 1/10/2026 and 1/15/2026. Record review of Resident #1's care plan dated 12/28/2025 revealed he did not have a care plan for shower or bathing refusals. It was documented as receiving showers/bed baths at least twice per week via shower sheets and CNA POC documentation under tasks. Interview on 1/20/2026 at 1:00pm Resident #1 said he was bathed but not as often as he would like. When asked if he had specific bathing days he said yes, Tues, Thurs and Fri but he does not get them all the time when he wants them. Asked what happens when he asks for his shower the resident said he had not asked, the staff should know. When asked if ever complained or filed a grievance about it, he shrugged his shoulders and then said yes. He said ultimately, I do not get showers as timely as I would like them, but I do get them. Interview with on 1/20/2026 at 3:28pm MDS Coordinator B said that there was a weekend person who helped with care plans and the 2 ADON's also helped with completing acute care plans and if there was a change in a resident's condition. She said care plans were completed quarterly, annually and when there was a change in condition. She said that she was aware that Resident #1 often refused showers and it should be addressed in the care plan. She said she did not know why it had not been done. She said it was just a human over site why it was not addressed on the care plan. At that point she said the care plan will be updated to address the resident's refusal of showers. In an interview on 1/20/2026 at 1:30pm CNA B said Resident #1 will agree to take a shower, and he would be in the shower chair and start screaming and yelling that he did not want a shower, he would rather take a bed bath. She said he would ask for bed bath and then call his daughter and tell her he did not get a shower. In an interview on 1/20/2026 at 4:00pm with ADON C and ADON D they said they initiated care plan for falls, change in condition and acute care plans. They said they were aware that Resident #1 always refused his showers, but they thought he was care planned for his refusals of showers. She said they would put him on the shower bed and then he would refuse to go to the shower room, and he would then decide he wanted a bed bath instead. They said he had dementia and after they would put him back in bed and give him a bed bath, as soon as they left the room, he would call his daughter and tell her he needed a shower. In an interview on 1/20/2026 at 4:15pm the DON, said it was the MDS Coordinator's duty to assess the resident and if there were any issues, she should address it on the care plan. She said care plans should be reviewed every 90 days and as needed and should be updated to address residents' needs. She said she was going to in-service staff and complete an audit of the care plans. Record review of the facility's policy and procedure dated 2001 titled Care Plans, Comprehensive Person-Centered read in part. Policy StatementA 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.Policy Interpretation and Implementation1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. participates in the planning process.b. identifies individuals or roles to be included.c. request meetings.d. request revisions to the care plan.e. participates in establishing the expected goals and outcomes of care.f. participates in determining the type, amount, frequency and duration of care.g. receives the services and/or items included in the plan of care; andh. see the care plan and sign it after significant changes are made.5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences.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:10. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.11. 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.

Based on interviews, and record review, the facility failed to ensure a Resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 34 residents (Resident #1) reviewed for ADL.The facility's 3rd shift nursing staff failed to or ignored Resident #1's call light in a timely manner, which has consistently occurred throughout a period of time [January 2025 through December 2025], leaving Resident #1 needing assistance for incontinent care for several hours.Resident #1 felt neglected, belittlement, and shame due to the facility's failure. These failures could cause residents to experience compromised dignity, comfort, and place residents at risk for skin infection. Findings included: Record review of Resident #1's undated Face Sheet dated revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE] with Resident #1 had an active diagnosis of CHF (heart muscle can't pump enough blood to meet the body's needs causing fluid buildup), Hypertension (Blood pushes too hard against artery walls), Diabetes (body doesn't make enough insulin in the body), Stroke (blood flow in brain is cut off), COPD (lung blockage), Parkinsonism (Neurological condition that causes tremors, and balance issues). Record Review of Resident #1's Care Plan dated 5/9/25 revealed the following:Focus: Resident #1 is at risk for decline in ADL functions and injury (Date Initiated: 11/17/24; Revision on 11/17/24).Goal: Resident #1 will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days (Date initiated: 11/17/24; Revision on 9/29/25; Target date 1/15/26).Interventions: Ensure call light is within reach answer promptly (Date initiated: 11/17/24). Record review of Resident #1's MDS dated [DATE] revealed she has a BIMS score of 15, which means a person's cognitive is intact, indicating normal thinking and memory with little to no impairment and totally dependent on staff for most of her ADL's, which are incontinent care (bathing, and changing,), rolling from left to right from a lying position, and personal hygiene. Record review of FM A's email dated 12/17/2025, revealed documentation of dates [starting from January 2025 thru December 2025] and times of various events provided by FM A, revealed nursing staff consistently ignored or refused to acknowledge Resident #1's call light for continent care, and when management staff were notified. The following dates were: 02/18/25, 03/01/25, 03/18/25, 04/05/25, 04/16/25, 04/28/25, 07/18/25, 07/24/25, 08/6/25, 08/19/25, 08/19/25 at 2:00am, 09/2/25 at 8:00am, 09/10/25, 09/11/25, 10/20/25 at 1:10am, 11/11/25, 11/21/25, 11/29/25, 12/4/25 at 9:00pm, 12/5/25 at 6:50pm, and 12/7/25 at 7:50pm.Record review of Facility's Incident report dated 12/17/25 does not reveal call lights not being answered.During an interview on 12/17/25 at 9:29 with FM #A stated the issues are mainly the night shift. FM A stated the night shift nurses leave resident sitting in her diapers because they don't answer the call button. He stated nurses will come in the room and just turn the call light off and leave right out without providing any care. FM A stated night nursing staff refuses to change or clean Resident #1 when she wets herself. FM A stated he has reached out to the administrator and has been told not to text his personal phone. FM A stated 02/18/25 nurses refused to change Resident #1 when she asked just before 11:00am saying she needed to wait till after lunch to be served. FM A stated on 03/18/25 at about 2:20am Resident #1 had called saying she asked to be changed, and a nurse or CNA said, it hasn't even been 2 hours and told her No. And turn the call light off and leave. An hour later 2 more nurses came in asking what's wrong she said she needed to be changed, and they said gimme a minute, turned the light off, and left and an hour after that she called saying she had been sitting in cold piss for over 3 hours. FM A stated on 04/16/25 Resident #1 called at 10:40pm saying she can't get anyone in her room to change her and that she had been asking since 6:30pm and that when she calls from her cell phone a nursing staff member picks up phone and says, ok and hangs up. FM A stated [DATE], Resident #1 called him at 3:10am crying cause she couldn't get changed saying she hadn't been changed since 9:00pm. I called the facility and was placed on hold with station #2 for 30 minutes and never got ahold of anyone. FM A stated Resident #1 called again at 3:50am during this call and someone finally came into the room to change her. FM stated Resident #1 should not be sitting in a soaked diaper with bedsores for hours. During an interview on 12/17/25 at 10:25am with Resident #1 she stated she has had a lot of issues with nursing staff, specifically on the 3rd shift, who refuse to answer her call light and give her incontinent care, by changing her diaper leaving her in urine and sometimes feces for hours. She stated the issues with her ill treatment by nursing staff began in January 2025 and has continued till this date. Resident #1 stated she's left in bed soaked because the third shift will not answer her calls or if they come into her room they berate her, scream at her and refuse to give her care [Resident #1 was unable to provide specific staff names, dates and details of these incidents]. Resident #1 stated staff will come in the room, then just turn off her call light or more often than not. Resident #1 stated she spoke with CNA A that her call light was not being answered which was mostly on 3rd shift. Resident #1 stated she felt neglected, belittled, and ashamed. Resident #1 stated FM A had specific times and days the issues started because she called FM A on these days and he documented this. Resident #1 stated talking to supervisors, management has gotten her and FM A nowhere.During an interview on 12/17/25 at 10:40am with Resident #2, who is Resident #1's roommate, she stated she has witnessed the verbal abuse (i.e., what do you want now? You've already changed so you will just have to wait. Can't wait until you leave. [Resident #2 was unable to provide staff names, dates or other specific details of these details]) from the 3rd shift staff and nurse regarding Resident #1. Resident #2 stated she doesn't have any issues and when she pushes her call button night shift staff responds to her, but they don't respond to Resident #1. She stated Resident #1 has been in a lot of pain and pushed her button and nursing very seldom respond. Resident #2 stated Resident #1 was in a lot of pain one night (could not remember the night or CNA staff name), so she pushed her own call button to get assistance for Resident #1. When CNA staff arrived to her room, Resident #2 told the CNA that she pushed her button by accident; however, Resident #1 has been pushing her button for a while and needed assistance because she was in pain. She stated the CNA just turned both call lights off and left the room without acknowledging Resident #1. Resident #2 was unable to remember the exact day or the CNA. Resident #2 stated she has heard LVN A and CNA's tell Resident #1 they didn't like her nor will they change her. Resident #2 stated Resident #1 often has had to wait until shift change and first shift nursing staff to change Resident #1 because the night nurse or CNA's refuse to do it or answer her call light.During an interview on 12/17/25 at 1:30pm with CNA A she stated she was familiar with Resident #1 and she has been told night shift nursing staff were verbally abusive to her [CNA A was unable to give nursing staff names or dates]. She stated she has also been told that the 2-10 shift and night shift hardly answers Resident #1's call light. CNA A stated she gets a lot of complaints from Station #2 residents regarding the lack of care from 2-10 and overnight shift. She stated she just passed the information on to the charge nurse on that day and in the past passed on similar concerns to ADON A.During an interview on 12/18/25 at 5:28am with LVN F she stated all residents needed to be checked on every two hours even if no call light is on. LVN F stated when she arrived for her shift (Night) she does rounds to see all residents and take nursing reports from the outgoing (second shift) nurse. LVN F stated Resident#1 is not difficult, but difficult within reason, which indicates that Resident #1 feels things aren't getting done her way she becomes irritated with a snappy attitude, but she is not aggressive and does not use profanity. LVN F stated if Resident #1 doesn't get along with someone or feels the nurse was rude to her, she will refuse care. She stated there was a CNA who felt Resident #1 was rude to her and would not provide care; however, LVN F stated she removed that can and replaced her with another one. When LVN F was asked if she has been unprofessional with Resident #1, she responded, she wants to say no she hasn't been unprofessional with Resident #1; however, there were interactions with Resident#1. LVN F stated Resident #1 never verbalized to her that she was having problems with other nursing staff other than another aide that Resident #1 said she was rude, which occurred 2-3 weeks. She stated she spoke with both, Resident# 1 and CNA. LVN F stated Resident 1 told her that she and the CNA didn't get along but didn't tell her specific incidents. LVN F stated she did not report the incident to anyone but feels like she should have said something management because the situation could have accelerated. LVN F stated Resident #1 is cognate and knows what she's talking about. LVN F stated she spoke with FM A regarding Resident # 1, needing to be changed one night. LVN F stated she asked Resident #1 had she been changed and Resident #1 stated she had not. At this time, she asked the CNA to change her. LVN F stated this has occurred on a couple occasions. During an Interview on 12/18/25 with Administrator he stated during a care Resident #1 mentioned her shirts were missing and the shirts were purchased by the facility. Administrator stated any issues or concerns Resident #1 FM A has his personal number. Administrator stated Resident #1 and FM A has not mentioned Resident #1 was being mistreated. Administrator stated FM A was last seen on Thanksgiving. Administrator denied ever telling FM A not to call his personal cell. Administrator denied FM A told him that Resident #1 was not being changed by nursing staff. Administrator stated Resident #1 has never told him she has concerns with any incontinent care being given by nursing staff. During an interview on 12/18/25 at 10:27am with ADON A she stated she has received complaints about staff not answering call lights and she has completed in-service training with staff regarding this issue. She stated she has not received any complaints for a specific staff member not answering call lights. ADON A stated she expects nursing staff members to be on time for work, make their rounds by seeing each resident, going into rooms to make sure residents' needs are met or if they needed anything, and to ensure all residents' call lights were in reach. She stated she usually see Resident #1 frequently or a couple of times a week when doing her rounds, but Resident #1 has never had any complaints regarding her care, nor had she told her nursing staff was rough with her. ADON A stated she has spoken with FM A regarding Resident #1's medications, but never regarding care. ADON A stated FM A has not called the facility in a while.During a telephone interview on 12/18/25 at 12:55pm with LVN E she stated she was assigned to station 2 and familiar with Resident #1. She stated she only provides nursing treatment, and she does not change residents. LVN E stated one CNA cannot change or transfer Resident #1 because she is overweight. LVN E stated two CNA's will change Resident #1 to avoid Resident #1 from falling on the floor. LVN E stated that she spoke with FM A on one occasion and wanted someone to check Resident #1's blood pressure. She stated she never knew that Resident #1 was having issues. LVN E stated CNA's are expected to do rounds every two hours or more to check on residents as needed. Record Review of Resident Rights policy dated February 2021 revealed, Employee show treat all residents with kindness, respect, and dignity.1. federal and state laws that guarantee certain basic rights to all residents of this facility. These rights include the residents right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;f. Communications with access to people and services, both inside and outside the facility;h. Be supported by the facility in exercising his or her rights.

Based on observation, interview and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 3 of 34 residents (Residents #10, #11, and #12,) reviewed for accidents and supervision. 1. The facility failed to ensure Residents #10, #11, and #12 were supervised while smoking on 12/18/2025 at 5:09 AM. 2. The facility failed to ensure Residents #10, #11, and #12 smoking supplies were stored securely when they were observed smoking unsupervised on 12/18/2025 at 5:09AM. These deficient practices could place residents at risk of burns causing injury or harm. Findings include: Record review of a Face Sheet for Resident #10 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included Unspecified Dementia (a severe decline in mental abilities, like memory, thinking, and reasoning, significant enough to disrupt daily life and activities), Mild protein-malnutrition (involves subtle but significant nutrient deficiency), hyperlipidemia (a condition with too many fats in the blood, often call high cholesterol), bipolar disorder (a mental health condition causing extreme mood swings from emotional highs to lows, affecting energy, judgement, and behavior), hypertensive heart disease (damage to the heart from long-term high blood pressure (hypertension) causing the heart muscle to thicken as it works harder), cognitive communication deficit, schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with those of a mood disorder), and major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of internet in activities). Record review of Resident#10's Quarterly MDS dated [DATE] revealed a BIMS score of 08 which indicated a cognition level of moderately impaired. Record review of Resident#10's undated care plan revealed a focus that Resident#10 was a tobacco smoker and is at risk for injury, encourage resident to wear a smoke apron. Interventions stated instruct encourage resident to wear a smoke apron while smoking, keep smoking material at nurses' station, review smoking policy w/ resident annually and PRN with concerns. Record review of a Face Sheet for Resident #11 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included Hemiplegia and hemiparesis following cerebral infarction affecting right non dominant side (damage to the brain's left hemisphere, impacting movement, coordination, balance, and potentially cognition), Atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in your hearts arteries that isn't causing chest pain yet), Heart failure, presence of cardiac pace maker, hyperlipidemia (a condition with too many fats in the blood, often call high cholesterol), hypokalemia (having low levels of potassium in your blood), Contracture, right hand. Record review of Resident#11's Quarterly MDS dated [DATE] revealed a BIMS score of 07 which indicated a cognition level that was severely impaired. Record review of Resident#11's undated care plan revealed a focus that Resident#11 was a tobacco smoker and is at risk for injury' required to wear a smoke apron related to contractures; refuses to wear a smoke apron. Interventions stated keeping smoking material at nurses' station; require supervision while smoking, required to wear a smoke apron. The care plan revealed another focus of . Smoking on patio for social interaction, resident requires direction assistance to attend; resident appears to be pre-occupied with smoking; episodes of not following the smoking policy. The residents' goal revealed resident will remain compliant with smoking policy and injury free. Interventions stated post activity calendar in room where resident can see, Remind/invite resident to scheduled activities of choice/interest; encourage resident to wear a smoke apron. Record review of a Face Sheet for Resident #12 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus, hereditary and idiopathic neuropathy, unspecified (refers to peripheral nerve damage where the cause isn't definitively genetic), hyperlipidemia (a condition with too many fats in the blood, often call high cholesterol), Unspecified Dementia (a severe decline in mental abilities, like memory, thinking, and reasoning, significant enough to disrupt daily life and activities). Record review of Resident#12's Quarterly MDS dated [DATE] revealed a BIMS score of 04 which indicated a cognition level that was severely impaired. Record review of Resident#12's undated care plan revealed a focus that Resident#12 was a tobacco smoker and is at risk for injury, encourage the resident to wear a smoke apron. Interventions stated encourage residents to wear a smoking apron while smoking. Keep smoking material at nurse's station. Observation on 12/18/25 at 5:09 AM of 3 (Resident #10, #11, and #12) residents smoking unsupervised in the smoking area. In an interview/observation on 12/18/25 at 5:10 AM; Resident #10 was observed smoking in the smoking area unsupervised with no apron on. Resident #10 stated the residents have smoke times but reported that they sometimes come out to smoke during this time (5 AM) on their own. She stated the smoke times did not start until 9am but reported that they sometimes wanted to smoke before then. She stated the staff keeps their smoking supplies and provides them when it is time to smoke. She stated she had gotten a cigarette from another resident but did not provide the name of the resident who provided her with the cigarette. Resident #10 was observed with no burn marks on her clothing or skin. In an interview/observation on 12/18/25 at 5:10 AM; Resident #11 was observed in the smoking area of the facility unsupervised. She stated that in the mornings she and others come out and smoke and there are never any staff members because it's not smoking times. She stated cigarettes and lighters are kept at the nursing station #1in a box. She stated no one ever told her that a staff member needed to be out in the smoking area with residents. Resident #11 was not observed with any burn marks on her skin or clothing. In an interview/observation on 12/18/25 at 5:15AM; Resident #12 was observed in the smoking area, smoking a cigarette unsupervised without an apron on. Surveyor attempted to interview the resident, but he stated, I don't have anything to say to you and proceeded to put his cigarette out and entered the building of the facility. In an interview on 12/18/25 at 5:25 AM with CNA- B; She stated the residents have smoking times, but they go out and smoke on their own at night. She stated the residents are not supposed to smoke on their own, but they do it anyway. She stated the residents have their own smoking supplies, she stated they are not supposed to keep their own smoking supplies, but they keep them anyway. She stated the smoking supplies are kept at station #1 nursing station. She stated the residents did not smoking times during night shift. She stated the administration staff were knowledgeable about the residents smoking unsupervised. She stated when she observes the residents smoking unsupervised, she redirects them and informs upper management. She stated the risk of the residents smoking unsupervised was that they could burn themselves or others. In an interview on 12/18/25 at 5:30AM with LVN-F; she stated she has been employed at the facility for 2-3 weeks. She stated she was not too familiar with the smoking policy because she works overnight, and the residents do not smoke on her shift. She stated she knows that the residents usually have assigned staff to supervise smoking on day and evening shifts but not overnight. She stated Resident # 11 was assigned to her hall and she usually gets up early in the morning to get coffee and she and other residents sit in the dining room area; she usually sees the resident on the way out. She stated the risk of residents smoking unsupervised could cause fire and if there is someone on oxygen then it would also be an issue. In an interview on 12/18/25 at 6:12 AM with CNA-C, she stated she worked night shift. She stated the residents had designated smoking times for day and evening shifts, but they did not have them for the night shifts. She stated there had never been a time that the residents had been smoking unsupervised during her shift. She stated if they noticed that residents were not in their rooms or in bed then they would go look for them. She stated residents were not allowed to keep cigarettes or lighters in their possession and that they were put in the lock box located on station 1. She stated the risk of the residents smoking unsupervised was they could set themselves on fire or set other things on fire. In an interview on 12/18/25 at 6:30AM with Administrator, he stated the smoking policy was that the residents are allowed to smoke in a designated area with supervised staff unless there was a visitor or family member with them. He stated staff were supposed to keep residents smoking supplies in a plastic container at the nurse's station. He stated the residents were not allowed to keep any of their supplies. He stated when residents go out to the store, they were asked if they have any smoking supplies and if so, they turn it in. He stated he was not aware that the residents were smoking unsupervised today. He stated he had been informed in the past that a resident had been smoking unsupervised. He stated he had a conversation with the resident, and the resident provided the cigarettes and lighter and it was stored at the nurse's station; residents name was not provided. He stated this was the only time that he had heard of residents smoking alone. He stated their smoking policy is when a resident is smoking unsupervised; they contact the RP, confiscate the items from the residents and if residents continue to not follow the smoking policy, then they would give the residents a 30-day discharge notice. He stated the risk of residents smoking unsupervised was the resident's dropping cigarettes on their clothes. He stated the residents had completed safe smoking assessments. In an interview on 12/18/25 at 2:38 PM with CNA-D, he stated he had witnessed Resident #12 and another resident (he could not remember the second residents name) smoking unsupervised a week or two ago and he notified the nurses. He stated he informed the nurse immediately-but he could not remember the name of the nurse he notified. He stated when he informed the nurse, they went outside and spoke with the residents and spoke with the residents, did a walk through, and collected smoking items that the residents had. He stated the risk of residents smoking unsupervised was that the residents could have a heart attack, choke, or burning themselves. Record review of Resident #10's smoking evaluation dated 09/21/25, revealed supervision will be required for all Residents during designated smoking times. poor vision or blindness, balance problems while sitting or standing, and follow the facility's policy on location and time of smoking. Record review of Resident #10's smoking assessment dated [DATE], revealed Resident #10 had cognitive loss, visual deficit, can light own cigarette, needed smoking apron and smoking supervision, and needed facility to store lighter and cigarettes. Record review of Resident #11's smoking evaluation dated 10/13/25, revealed supervision will be required for all Residents during designated smoking times. poor vision or blindness, balance problems while sitting or standing, and follow the facility's policy on location and time of smoking. Record review of Resident #11's smoking assessment dated [DATE], revealed Resident #11 had cognitive loss, visual deficit, dexterity problem, cannot light own cigarette, needed smoking apron and smoking supervision, and needed facility to store lighter and cigarettes. Record review of Resident #12's smoking evaluation dated 10/27/25, revealed supervision will be required for all Residents during designated smoking times. poor vision or blindness, balance problems while sitting or standing. Record review of Resident #12's smoking assessment dated [DATE], revealed Resident #12 had cognitive loss, visual deficit, dexterity problem, can light own cigarette, needed smoking apron and smoking supervision, and needed facility to store lighter and cigarettes. Record review of the facility Smoking policy dated March 2025 revealed: This facility has established and maintains safe resident smoking practices.12. Residents are allowed to smoke in the designated smoke area under the supervision of staff or a family member/visitor during visitation and smoking times, which are posted at the nurses station (s). 13. Residents and/or families are required to turn in all cigarette products and lighters to be stored in a container at the nurse station.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 4 staff (CNA A) and 2 of 3 residents (Resident #3 and Resident #4) reviewed for infection control.CNA A failed to place Resident #3's Hoyer transfer sling and bed sheets in the appropriate linen barrel after use and placed them in the rubbish bin at the resident's bedside.CNA A failed to place Resident #4's bed blanket in the appropriate linen barrel and tried to replace it on the resident's bed after it had been lying on the floor. These failures could place residents at risk for cross contamination, infection and decline in health. Findings include: Resident #3Record review of Resident #3's admission Record revealed she was a [AGE] year old female who admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of sepsis (a systemic infection with life threatening organ dysfunction), quadriplegia (a medical condition characterized by the partial or complete loss of movement and sensation in all four limbs), cerebral edema (a condition where excessive fluid accumulates in the brain tissue, causing it to swell), methicillin-resistant staphylococcus aureus (a strain of bacteria that is resistant to the antibiotic methicillin and other similar antibiotics), tracheostomy status (a surgical procedure that creates an opening in the front of the neck into the windpipe for breathing), pressure ulcer of sacral region, stage 4 (a severe wound that involves full-thickness skin and tissue loss with exposed underlying structures like muscle, tendon, ligament, cartilage or bone), and gastrostomy (a surgical procedure that creates an opening in the abdominal wall directly into the stomach that allows a tube to be inserted into the stomach for feeding). Record review of Resident #3's Modified admission MDS dated [DATE] revealed she had a Staff Assessment for Mental Status (SAMS) and was coded as being severely impaired in cognitive skills for daily decision making. She was dependent on staff for assistance with all ADLs. Record review of Resident #3's physician order summary dated active orders as of 10/08/2025 revealed the following order: enhanced barrier precautions for wounds, and had a start date of 9/13/2025, with no stop date. Interview and observation on 10/7/25 at 11:55 a.m., with LVN A who came to Resident #3's bedside to view the linens stuffed inside the resident's bedside rubbish bin, LVN A said she was not sure what the linens were or how they got there, but they did not belong in the bin because that was not the correct place for dirty or clean linens. LVN A said Resident #3 was at increased risk for infection because of her medical conditions and the linens could be a source of infection if they left in the room improperly. LVN A left to retrieve CNA A, the Administrator and the DON. Observation and interview on 10/7/25 at 12:08 p.m., with the Administrator, DON and CNA A in Resident #3's room, CNA A said she was assigned to Resident #3 and did not know how the items ended up in the rubbish bin at the resident's bedside and that they did not belong there. CNA A was asked to remove the items inside the trash bin which revealed a soiled Hoyer lift sling and a soiled yellow stained white bedsheet. Both items appeared to be wet and saturated with liquid. CNA A repeated that the items did not belong in the rubbish bin and that she did not know how the items got inside the trash bin. CNA A tried to bring a linen barrel to Resident #3's bedroom door to remove the linens but the Administrator and DON arrived at the resident's room prior to the removal of the items. The DON removed the bundled items with her gloved hands, that CNA A had placed back into the bedside trash bin and said it was a soiled Hoyer sling used for resident transfers and a soiled bedsheet. The DON said they did not belong inside a resident's bedside trash bin because it could spread infection if not handled and disposed of properly. The DON said the IP would do an immediate reeducation with assigned staff member CNA A. The Administrator asked what the items were and when shown the soiled linens, by the DON said they did not belong inside the trash bin and he and the DON would speak with the staff member involved and retrain them because staff had been trained on how to handle and dispose of linens properly as part of infection control training. The Administrator said leaving soiled linens in a trash bin in any resident room could spread infection. CNA A was observed speaking with the DON, LVN A and the Administrator while she began removing the soiled linens out of the trash bin and placing them in the required linen receptacle. Resident #4 Record review of Resident #4's admission Record revealed he was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted to the facility 9/17/25 with a diagnosis of acute and chronic respiratory failure ( a condition where a person with an underlying chronic respiratory disease experiences a sudden and severe worsening of their breathing), colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall which allows stool and gas to pass directly into a collection bag worn on the outside of the body), tracheostomy status (a surgical procedure that creates an opening in the front of the neck into the windpipe for breathing), gastrostomy (a surgical procedure that creates an opening in the abdominal wall directly into the stomach that allows a tube to be inserted into the stomach for feeding), and peripheral vascular disease ( a condition where the blood vessels outside the heart and brain become narrowed or blocked, reducing blood flow to the limbs). Record review of Resident #4's Admission, 5-day MDS dated [DATE] revealed he had a Staff Assessment for Mental Status (SAMS) and was coded as severely impaired in cognitive skills for daily decision making and he was dependent on staff for assistance with all ADLs. Record review of Resident #4's physician order summary dated active orders as of 10/08/2025 revealed the following order: enhanced barrier precautions AEB colostomy and had a start date of 6/13/2025 with no stop date. Observation on 10/7/2025 of Resident #4 at 12:22 p.m., who was located in the room across the hallway from Resident #3 and had an EBP sign posted on the door and an adequate supply of PPE outside the bedroom door. Resident #4 had a navy-blue blanket lying on the floor in a bundle on the floor at the foot of his bed. Resident #4 was appropriately dressed and groomed and was lying on an air mattress in a clean facility gown with a clean white sheet at the end of the bed. His gastrostomy tube was connected to his enteral feeding (a method of providing nutrition directly into the stomach through a tube), that was infusing via a bedside pump as per MD orders. His tracheostomy and collar were in place and secured with his oxygen infusing via bedside concentrator per MD orders. In an interview and observation on 10/7/25 at 12:24 p.m., CNA A entered Resident #4's room and picked up the navy-blue banket off of the floor and began to shake it out in an attempt to line up the corners and edges of the blanket to fold it. CNA A said that Resident #4 did not like to keep the sheets and blankets on and would kick them off sometimes when he did not want them. CNA A began to place the navy-blue blanket across the lower legs and feet of Resident #4 before the surveyor stopped her. When asked why she would put the blanket from the floor back on the resident's bed and not in the dirty linen barrel, she replied, I guess I can. CNA A walked out of Resident #4's room rapidly before the surveyor could ask another question and was not seen at the facility for the remainder of the investigation. Interview with the IP on 10/8/25 at 9:20 a.m., who said they completed a 1:1 in-service training with CNA A on 10/7/25 and that CNA A had also been trained on infection control and proper linen handling prior to the incident with Resident #3 and Resident #4 on 10/7/25. The IP said both Resident #3 and Resident #4 were on EBP and could get infections, worsen any existing infections or illnesses if their linens were not handled properly. The IP said both Resident #3 and Resident #4 had tracheostomy and gastrostomy tubes and that was the reason for their EBP status. Record review of training in infection control that included proper handling of linens that CNA A signed on 10/7/25 and 8/12/25. Record review of facility policy and procedure titled Enhanced Barrier Precautions dated 2021 revealed in part: Enhanced Barrier Precaution's (EBP's) are utilized to reduce the transmission of multi drug resistant organisms (MDRO's) to residents.5. EBP's are indicated (when contact precautions do otherwise not apply) for residents with wounds and or indwelling medical devices. Record review of facility policy and procedure titled Standard Precautions dated 2021 revealed in part: a. linen soiled with blood, body fluids, secretions, excretions, are handled and processed in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to the other residents and environments.

Based on observation, interview and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside.Based on observation, interview and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 out of 10 (Resident #2) of the residents reviewed for call-lights. The facility failed to ensure Resident #2 had a functioning call light, the call light was empty inside the device, presenting only the white outer coating. This failure could lead to residents not being able to request and receive prompt medical care and result in injury and harm.Findings included:Record review of Resident #2's face sheet, dated, reflected an [AGE] year-old female originally admitted to the facility on [DATE] and last re-admitted [DATE] with a diagnosis of (a systemic infection with life threatening organ dysfunction), quadriplegia (a medical condition characterized by the partial or complete loss of movement and sensation in all four limbs), cerebral edema (a condition where excessive fluid accumulates in the brain tissue, causing it to swell), methicillin-resistant staphylococcus aureus (a strain of bacteria that is resistant to the antibiotic methicillin and other similar antibiotics), tracheostomy status (a surgical procedure that creates an opening in the front of the neck into the windpipe for breathing), pressure ulcer of sacral region, stage 4 (a severe wound that involves full-thickness skin and tissue loss with exposed underlying structures like muscle, tendon, ligament, cartilage or bone), and gastrostomy (a surgical procedure that creates an opening in the abdominal wall directly into the stomach that allows a tube to be inserted into the stomach for feeding).Record review of Resident 's Modified admission MDS dated [DATE] revealed she had a Staff Assessment for Mental Status (SAMS) and was coded as being severely impaired in cognitive skills for daily decision making. She was dependent on staff for assistance with all ADLs.Record review of Resident #2's physician order summary dated active orders as of 10/08/2025 revealed the following order: enhanced barrier precautions for wounds, and had a start date of 9/13/2025, with no stop date. Record review of Resident #2's care plan reflected she was at risk for falls, aspiration related to feeding tube in place, respiratory distress, impaired communication, self-isolation, shortness of breath, chest pain, elevated blood pressure. --Receiving (In-house dialysis) She was also care-planned for self-care deficits related to ADLs and requires total assistance for bathing, dressing, eating, mobility, and risk further decline due to trach placement and cognition.Observation and attempted interview on 10/07/2025 at 11:25 a.m., Resident #2 was in bed with contracted hand near call light exposing an empty hold where the push device would be located inside the outer white casing. The resident was not able to be interviewed and did not respond to questions. Interview and observation on 10/07/25 at 12:08 p.m., the Administrator and DON, employed at the facility since January 2025, he said maintenance and the nursing staff should check to make sure the call lights were in good condition before they were placed within reach for the resident for them to use. The Administrator said if the call button being functioning the residents would not be able to alert staff for assistance or harm. The Administrator said that residents might need medication, and if they did not have their call light within reach there could be a multitude of things that could go wrong. The Administrator said the call light in Resident #2's room will be changed and staff provided in services. He picked up the call light to observe the push button portion of the call button missing. The DON, she said all residents should always have call light with reach. The DON observed the call light laying on the resident's bed. The DON said it is a safety issue in case the resident needed to request care. The DON said immediate reeducation with staff and maintenance would occur. Interview on 10/08/25 at 12:25 p.m., CNA A employed at the facility for seven months, she said the expectation is to check residents every two hours or as needed. She stated she did not know Resident #2's call light was not functioning. She stated she is aware Resident #2 was a nonverbal resident, and she is only mobile with assistance. She stated she was made aware the call light was not working on 10/07/2025. She stated she knows she was supposed to check the call lights. She said that it was on staff for not checking her call light to know it was broken. She said she had been working with Resident #2 for a month and a half. Interview on 10/07/25 at 12:34 p.m., CNA B, employed at the facility for two years, stated she was not aware of Resident #2 call light being broken. She said that Resident #2 was not a resident room that she works with often. She said all its staff can check for call button function. She said very serious outcomes can occur when a call light is not operating such as falls, aspiration, or death. Interview on 10/07/25 at 12:45 p.m., LVN A, employed at the facility for one week, she stated she was not aware of Resident #2 call light being broken. She said she worked at the opposite end of the hallway and is not familiar with Resident #2. She said very serious outcomes can occur when a call light is not operating such as falls, chocking, or death. Interview on 05/22/25 at 1:33 p.m., the HR/Payroll Director, employed at the facility for many years, said she said she confirms the rooms are ready to move and checks call lights for proper functioning and operating daily. She said the CNAs check resident's morning, lunch, and she stated anyone can answer call lights at the community. She said the expectation is to check residents every two hours or as needed. She said she was not aware of Resident #2's call light being broken. She said she is aware the call light has been changed and replaced with a more accessible call light and in-service has been provided.Interview on 05/22/25 at 1:40 p.m., the Maintenance Director, who has been employed at the facility since 2001, said he confirms all call lights are functioning properly and operating. He stated that anyone can answer call lights at the community. He said call lights are his main priority at the community. He said he checks call lights weekly. He said companies do not make call lights like they used to; they break easier than they used to. He said he always keeps 10 extra buttons just in case they are needed. He said last Friday he checked all the call buttons in the building and Resident #2 light was not broken. He said he does not recall a resident being in that room. He said if a call light is pulled out it will sound off continuously until it is replaced with another button. He said sometimes the CNAs may switch broken buttons out themselves and not report it to maintenance, that's what could have happened. He said he really does not know how he could have missed a broken button because he conducted a thorough audit of call lights last Friday.Record review of the maintenance binder did not reflect any broken call light reports related to Resident #2. Record review of the facility's call lights policy last revised 09/2022 read in part, The Facility will provide each resident with a means to call staff directly for assistance from his or her bed for from toileting/ bathing facilities and from the floor. The call system communication may be audible or visual, wired or wireless. The resident calls system remains functional at all times, if audible communication is used the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights must remain functional. If the resident has a disability that prevents him or her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. The resident call system is routinely maintained and tested by the maintenance department.

Based on observations, interviews and record reviews the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #77) out of 6 residents reviewed for pain management. The facility failed to ensure Resident #77's pain medications were administered timely prior to traveling in an ambulance to the dialysis facility on 07/23/25 when he rated his pain as an 8 out of 10 pain scale. This failure could place Resident #77 and other residents at risk of not receiving timely pain management care which could result in prolonged pain and diminished quality of life.Findings included: Record review of Resident #77's face sheet dated 07/23/25 revealed a [AGE] year-old male readmitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. His diagnoses included fracture of the shin bones of left and right leg, COPD (chronic obstructive pulmonary disease - a lung condition caused by damage to the airway), end stage renal disease (kidneys no longer function adequately requiring dialysis or transplant), cirrhosis of the liver (abnormal liver function), Osteoarthritis (degeneration of joint cartilage and bone), hypotension, heart failure, depression, anxiety, chronic pain syndrome and dependence on renal dialysis. Record review of Resident #77's quarterly MDS dated [DATE] revealed a BIMs score of 14 out of 15 indicating intact cognition. He had no behaviors or rejection of care. He used a wheelchair for mobility. Pain intensity over the last 5 days was rated at a 6 out of 10, with zero being no pain and 10 being the worst pain ever imagined. Further review revealed he was taking antianxiety and opioid medications. Record review of Resident #77's undated care plan revealed: Focus - Resident #77 was at risk for increased pain and further decreased circulation as evidenced by venous ulcers to bilateral lower extremities. Interventions included - give medications per order. Focus - Resident #77 was on pain medication therapy Oxycodone r/t disease process. Interventions included - administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Focus - Resident #77 had chronic pain r/t neuropathy. Interventions included: anticipate the resident's need for pain relief and response immediately to any complaint of pain. Focus - Resident #77 had episodes of manipulative behaviors as evidenced by pain med seeking behavior and at risk for further episodes. Interventions included - distract resident with activities based on resident's preferences, notify MD/RP of behaviors. Focus - Resident #77 at risk for further skin breakdown r/t left lower leg, closed surgical on 6/10/25. Interventions included - observe for pain, give medication per order, check for relief. Focus - Resident #77 needs dialysis r/t renal failure, M/W/F. Interventions included - work with resident to relieve discomfort for side effects of the disease and treatment.Focus - Resident #77 was at risk for shortness of breath, chest pain, elevated blood pressure, infected access site, dry/itchy skin as evidenced by diagnosis of ESRD. Dialysis schedule: 3 times per week on M/W/F. Pick up time: 7:00AM, revised on 02/04/25. No recent revisions were made. Record review of Resident #77's order summary report of active orders as of 07/23/25 revealed orders for: -Oxycodone HCL oral tablet 10mg every 12 hours at 9:00AM and 9:00PM for pain management, order date 07/10/25. -Oxycodone HCL oral tablet 5mg every 6 hours as needed for pain, order date 06/24/25. -Hydrocodone-Acetaminophen oral tablet 10-325mg one tablet every 6 hours as needed for pain, order date 07/02/25. -Methocarbamol 750mg every 12 hours at 9:00AM and 9:00 PM for muscle relaxer, order date 06/10/25 - May go to dialysis on: Monday, Wednesday, Friday at 7:00 AM, order date 06/10/25.Record review of Resident #77's completed orders revealed and order started 06/10/25 for taper dose of Oxycodone HCL 10mg: give 4 tablets by mouth every 12 hours for pain for 6 days, 1 tablet for 7 days; give 3 tablets by mouth every 12 hours for pain for 7 days, 1 tablet for 7 days; give 2 tablets by mouth every 12 hours for pain for 7 days, 1 tablet for 7 day; give 1tablets by mouth every 12 hours for pain for 7 days, 1 tablet for 7 day. The end date for the order was 07/08/25. Record review of Resident #77's June 2025 MAR/TAR revealed pain assessments were completed every shift and pain scores were zero to 5 out of 10. Record review of Resident #77's July 2025 MAR revealed the Oxycodone HCL 10mg to be given every 12 hours, due at 8:00 AM was not given on 7/2/25 and 7/14/25. Further review revealed the Methocarbamol 750mg tablet every 12 hours at 9:00 AM and 9:00 PM for muscle relaxer was not given at 9:00 AM on 07/02/25, 07/14/25 and 07/23/25 and to refer to the progress notes for both Oxycodone HCL 10mg and Methocarbamol 750mg. Record review of Resident #77's Administration progress note revealed on 07/02/25 at 8:29 AM, MA-E noted the resident was at dialysis. On 07/14/25 at 11:52 AM, CNA-H documented the resident was at dialysis. On 07/23/25 at 8:38 AM, CNA-B documented the resident was at dialysis. Record review of Resident #77's July 2025 MAR revealed from 7/01/25 to 07/24/25: - Hydrocodone-Acetaminophen oral tablet 10-325mg one tablet every 6 hours as needed for pain was documented as administered 2-4 times per day. Pain levels were documented as 4 to 8 out of 10 (10 being the worst pain imagined). All administrations were documented as effective.-Oxycodone HCL 5mg every 6 hours as needed for pain was documented as administered 17 days, 1 to 3 times per day. Pain levels were documented from 4 to 9 out of 10. All administrations were documented as effective. -The scheduled Oxycodone 10mg twice a day was documented as administered. -Further review revealed Resident #77 was monitored for opioid adverse events every shift. Most entries revealed none was observed. Record review of Resident #77's Administration notes written by RN-A revealed on 07/23 25 at 8:38 AM it was noted the resident was at dialysis. On 07/23/25 at 9:00AM a note by RN-A revealed the follow up pain scale was 0 and effective. On 07/23/25 at 2:00 PM, RN-A documented the administration of Oxycodone HCL 5mg tablet by mouth every 6 hours as needed for pain: request for pain medication for breakthrough leg pain. Further review revealed there was no follow up pain assessment. Record review of Resident #77's July 2025 administration progress notes revealed on 07/23/25 at 3:00 PM, RN-D noted the administration of Hydrocodone/Acetaminophen 10-325mg every 6 hours as needed for pain: one tablet given as directed. Record review of Resident #77's July 2025 MAR revealed on 07/23/25 at 3:00 PM, the resident received Hydrocodone/Acetaminophen 10-325mg and RN-D noted the pain level of 5 and that it was effective. Record review of Resident #77's Administration progress note on 07/23/25 at 3:51 PM, revealed RN-A documented Hydrocodone/Acetaminophen 10-325mg follow up pain was: 0 and the administration was effective. Record review of Resident #77's History and Physical, date of service 7/2/25, by Physician-F revealed he had fracture pain and was still appropriate to continue for Hydrocodone-Acetaminophen 10-325mg and Oxycodone. Continued review indicated the resident was known to have alcohol abuse and very close monitoring would be needed in the facility for s/sx of intoxication and withdrawal. Record review of Resident #77's nurse note dated 07/02/25 at 5:11 PM and written by the ADON/IP indicated that the resident expressed that he had been drinking large amounts of alcohol the prior night. Further review of the nurse note indicated ADON/IP educated the resident of the risks of drinking alcohol and taking medication regimen. Continued review indicated the resident verbalized understanding, and the NP/MD were made aware. Record review of Resident #77's behavior note dated 07/02/25 at 6:00 PM and written by LVN-G, indicated Resident #77 refused medication from the med aide and med aide reassured the medication would be provided, but he still refused. Further review revealed RN-D wrote on 04/25/25 at 7:06 AM, Resident #77 was upset because the Hydrocodone-Acetaminophen oral tablet 10-325mg could not be given at the time due to the fact the night time nurse had given a dose at 5:00 AM. Continued review of Resident #77's behavior notes dated 09/24/22 to 07/17/25 revealed no documentation regarding the resident crying out in pain. Record review of Resident #77's Administration progress notes on 07/02/25 at 8:29AM noted the resident went to dialysis. Continued review of the progress notes revealed an administration note on 07/14/25 at 7:32AM for Hydrocodone-Acetaminophen 10/325mg. The next entry was on 07/14/25 at 11:52, AM and noted the resident was at dialysis. There was no entry on 07/14/25 noting the resident was at dialysis at 9:00AM. Record review of Resident #77's Medical Professional Note, date of service 7/9/25 by Physician-F revealed in part: .Pain Management Continue Oxycodone 10 mg every 12 hours scheduled and 5 mg every 6 hours as needed for breakthrough pain. Also continue Hydrocodone-Acetaminophen 10-325 mg every 6 hours as needed. Monitor pain levels, effectiveness of regimen, and signs of sedation, constipation, or misuse. Consider simplifying opioid regimen to avoid overlapping narcotics if sedation or altered mental status arises. Observation and interview on 07/22/25 at 12:56PM, revealed Resident #77 was in the dining room, reclined in a specialized wheelchair. He had an external fixator/traction device, the pins were in his left leg. He had dressings to his feet. He was feeding himself and in no distress. Resident #77 stated he was hit by a truck and was in the hospital for surgery to his leg. Observation and interview on 07/23/25 at 6:55 AM, Resident #77 stated the transportation to dialysis would be arriving soon and that he was due for pain medications: Oxycodone and Hydrocodone-Acetaminophen 10-325mg at 7:30AM. He stated sometimes it may take 2.5 hours before he received pain meds after he asked for them. He stated because of the delay in receiving pain medication when he requested, it would disrupt his medication schedule preventing him from adequate pain control before going to dialysis. He stated it infuriated him and sometimes he cried when he ended up missing a dose of pain medication. He was observed scratching his skin and moving his upper body without any hesitation. At 7:15 AM Resident #77 turned on the call light. Nursing staff answered a few minutes later. Resident #77 requested his pain meds and told the nurse he was going to dialysis very soon. Resident #77 stated he usually asked multiple times to get what he needed before leaving for dialysis and at times he would not receive his pain meds. He stated his pain was in his leg and his back. At 7:35 AM RN-A assessed Resident #7, checked his vital signs then Resident #77 told her his pain level was 8 out of 10. Interview on 07/23/25 at 7:45 AM, RN-A stated Resident #77's Oxycodone was scheduled every 12 hours and was due at 9:00AM, the Hydrocodone-Acetaminophen 10-325mg was as needed for pain. RN-A stated she would need to wait closer to 8:00AM to administer the medications as the scheduled Oxycodone could only be given one hour before or one hour after 9:00 AM RN-A stated the plan was to wean down the amount of narcotics Resident #77 was taking and that he had history of drug seeking and that he was used to the drugs he was receiving while in hospital. Observation on 7/23/25 at 7:55 AM, revealed Resident #77 was in the gurney as transportation attendants wheeled the resident down the hall. Observation on 7/23/25 at 8:00AM revealed Resident #77 was taken back to his room. RN-A administered Oxycodone IR 10mg and Hydrocodone-Acetaminophen 10-325mg one tablet to Resident #77, attendants then wheeled him back down the hall to transport in the ambulance to dialysis. IIn an Interview on 07/24 25 at 9:30AM, ADON-I stated she would expect a resident's pain to be addressed in a timely manner, get them the pain med, offer repositioning, if still not working she would notify the MD. ADON-I stated 2 hours is not acceptable for waiting on pain med and maybe 1-2 hours would be maximum, but she was unsure and would have to check the policy. ADON-I stated the pain level would depend on the individual resident's interpretation of pain. ADON-I stated if the pain level was a 4 or 5 and the resident was comfortable and wanted more pain medication, she would administer what was due, try repositioning or call the doctor. ADON-I stated she expected the nursing staff to do the same. ADON-I stated no one wants to be in constant pain, the resident may be grumpy and not want to do any ADLs. ADON-I stated it could worsen their health status. ADON-I stated medications can be given one hour before or one hour after scheduled order for time. ADON-I stated Resident #77 was followed by pain management doctor at one time, she was unsure but may be due to insurance. ADON-I stated Resident #77's pain management was under Physician-F who was the primary care physician. In an interview on 07/24/25 at 9:45 AM, the ADON/IP stated she was familiar with Resident #77. The ADON/IP stated if a resident asks for pain medication immediately, she expected nursing staff to check in 30minutes to see if the pain had subsided and if not, she would notify the MD for further instructions. The ADON/IP stated they[BR10] would try comfort measures as well to help manage pain. The ADON/IP stated if a resident had uncontrolled pain, she would contact the MD to adjust the meds. The ADON/IP stated most of the time medications would be scheduled around appointments, if not then the MD would be contacted to reschedule. The ADON/IP stated Resident #77 had a pain specialist and then pain management was transitioned to the provider. The ADON/IP stated transportation for dialysis would usually leave at 8:15am and as far as she knew he was receiving the 9:00AM meds before leaving. The ADON/IP stated Resident #77 does have breakthrough pain, she visits with him on multiple occasions and had not mentioned any issues about not getting his pain meds. The ADON/IP stated the medication aide was responsible for administering his 9:00AM medications and if they were missed, she expected to be notified so she can contact the MD and adjust the times. In a telephone interview on 07/24/25 at 12:40 PM, Physician-F stated he was very familiar with Resident #77 and that he was responsible for managing his pain meds. Physician-F stated Resident #77 was pain med seeking and that his subjective determination of pain can be different for everyone and his was a little bit off. Physician-F stated he does not use a pain scale but uses objective findings instead. Physician-F stated he received calls about his pain every week about his pain status and the nurses will also text him on his cell phone frequently. Physician-F stated he sees Resident #77 three days a week and would have complaints about pain. Physician-F stated Resident #77 can get his medications either before or after dialysis and he had already made the changes when ADON/IP notified him. In an observation and interview on 07/23/25 at 1:45 PM, revealed Resident #77 returned from dialysis and was in the dining room playing cards, no distress was noted. He stated normally it would take about one hour to receive his pain medications. When asked if he remembers what time he asked for pain medication this morning, he stated it was just before the surveyors entered his room around 7:00AM. He stated the ride in the ambulance was rough and his pain level was 8-9/10 at the time. He stated he would ask the drivers to avoid bumps in the road, but they could not promise that. In an Interview on 07/24/25 at 1:47 PM, LVN-C stated when Resident #77 requests pain medication, he reports his pain to be a 7 or 8 out of 10, she would then check which pain medication could be given. LVN-C stated she has seen Resident #77 cry or scream loudly in the last month when he did not get his pain medications when he asked. LVN-C stated she would address the pain by offering available pain medication, repositioning such as moving him into his wheelchair and if that did not work, she would contact the MD for further instructions. Interview on 07/24/25 at 2:00 PM, RN-D stated Resident #77 received all his scheduled and PRN pain medications. RN-D stated his tolerance to pain medications was high, however with his illness and injury he was often in pain and that his pain level was a 7 or 8 out of 10. RN-D stated she would use non-pharmacological interventions to help him with the pain. RN-D stated he did well when up in the wheelchair with activities for distraction. RN-D stated she would contact the physician after two to three episodes of no pain relief for further instructions. Interview on 7/25/25 at 9:40 AM, RN-A stated on dialysis days she was aware Resident #77 would be gone for at least 6 hours and that he would need the pain coverage so that was why she gave both the Oxycodone and Hydrocodone-Acetaminophen oral tablet 10-325mg at 8:00 AM on 07/23/25. RN-A stated sometimes it could take a little time to get what Resident #77 needed especially when in the middle of doing something for another resident and could not always respond as quickly as he would like but she tried to get to him in an hour or less. Record review of the facility policy and procedure for Administering Pain Medication, revised October 2022, revealed in part: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication.General Guidelines 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals.5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after onset and reassessed as indicated until relief is obtained.7.a. Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose.9. Re-evaluate the resident's level of pain 30-60 minutes after administering.

Based on observation, interview and record review the facility failed to ensure that residents were free of significant medication error for 1 of 6 residents (Resident #77) reviewed for medication administration.The facility failed to ensure Resident #77 received the correct controlled substance for pain medication as ordered by the physician leading to multiple opioid administrations between 06/12/25 and 07/26/25.-Resident #77's narcotic sheets for Oxycontin ER 10mg contained documented sign out dates from 06/12/25 to 07/26/25. There were no physician orders for Oxycontin ER 10mg.-Resident #77's narcotic sheet for Oxycodone IR 10mg one tablet every 12 hours contained documented sign out dates that did not match the instructions on the pharmacy label. These failures could place other residents at risk of medication errors, opioid overdose, CNS depression, respiratory distress and death.Findings included:Record review of Resident #77's face sheet dated 07/23/25 revealed a [AGE] year-old male readmitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. His diagnoses included fracture of the shin bones of left and right leg, COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway, end stage renal disease (kidneys no longer function adequately requiring dialysis or transplant), cirrhosis of the liver (abnormal liver function), Osteoarthritis (degeneration of joint cartilage and bone), hypotension, heart failure, depression, anxiety, chronic pain syndrome and dependence on renal dialysis. Record review of Resident #77's quarterly MDS dated [DATE] revealed a BIMs score of 14 out of 15 indicating intact cognition. He had no behaviors or rejection of care. He used a wheelchair for mobility. Pain intensity over the last 5 days was rated at a 6 out of 10, with zero being no pain and 10 being the worst pain ever imagined. Further review revealed he was taking antianxiety and opioid medications. Record review of Resident #77's order summary report of active orders as of 07/23/25 revealed orders for: -Oxycodone HCL oral tablet 10mg every 12 hours for pain management, order date 07/10/25. -Oxycodone HCL oral tablet 5mg every 6 hours as needed for pain, order date 06/24/25. -Hydrocodone-Acetaminophen oral tablet 10-325mg one tablet every 6 hours as needed for pain, order date 07/02/25. - Resident #77 had no documented orders for Oxycodone ER 10mg.-Hydrocodone/Acetaminophen 10/325mg, one tablet every 6 hours as needed for pain-Methocarbamol 750mg, one tablet every 12 hours for muscle relaxer-Gabapentin 100mg, 2 tablets every Monday, Wednesday, Friday after dialysis for neuropathy (condition that damages nerves and can cause pain) Record review of Resident #77's completed physician's order for tapering of Oxycodone HCL(IR) 10mg ordered on 06/10/25 revealed: - 4 tablets every 12 hours for 7 days, start date 06/11/25. - 3 tablets every 12 hours for 7 days, start date 06/17/25. - 2 tablets every 12 hours for 7 days, start date 06/24/25. - 1 tablet every 12 hours for 7 days, 07/01/25 and end date 07/08/25. Record review of Resident #77's Pharmacy Controlled Substance Prescriptions revealed: - 06/09/25 a prescriber from the hospital ordered Oxycontin (Oxycodone) ER 10mg to start on 6/09/25 included taper orders. -On 06/10/25 the pharmacy dispensed Oxycontin ER 10mg and this was used by the facility on 06/12/25 to 06/27/25. -On 06/10/25, Resident #77's physician ordered Oxycodone HCL(IR) 10mg, with taper orders to start 06/11/25 and end 07/08/25. -On 06/24/25 the pharmacy dispensed Oxycontin ER 10mg (instead of Oxycodone HCL(IR) 10mg). Oxycontin was used by the facility 06/28/25 to 07/26/25. Record review of Resident #77's narcotic sign sheets revealed: - Oxycontin ER 10mg, with the taper orders (4 tablets every 12 hours for 7 days, 3 tablets every 12 hours for 7 days, 2 tablets every 12 hours for 7 days, 1 tablet every 12 hours for 7 days) was signed out 06/12/25 to 06/27/25. The hospital physician was listed as the prescriber on the pharmacy label and not Resident #77's facility Physician. -Oxycontin ER 10mg, received on 06/24/25, had instructions on the label for the above taper orders, doses were signed out on 06/28/25 to 07/26/25. The hospital physician was listed as the prescriber on the pharmacy label and not Resident #77's facility Physician. - Oxycodone IR 10mg every 12 hours, received on 07/04/25, and doses were signed out on 07/04/25 and signed out on various dates through to 07/23/25. The signed dates were inconsistent with the instructions on the pharmacy label and not given every 12 hours. Record review of Resident #77's June and July 2025 MARs printed on 07/23/25 indicated nursing staff documented administration of Oxycodone HCL 10mg taper orders starting 06/11/25 to 07/08/25 then continued documenting twice daily until 07/26/25 except for 07/10/25, 07/11/25, 7/15/25, 07/21/25 when only one dose daily was administered. Resident #77 had no order listed on the MARs for Oxycontin ER 10mg taper orders. Record review of Resident #77's July 2025 MAR printed on 07/25/25 indicated nursing staff documented the administration of Oxycodone HCL 10mg 1 tablets every 12 hours for 7 days: -07/01/25 at 8:00 PM, 07/02/25 8:00 AM dose was held and not given, 8:00PM dose was given. Resident #77 received the medication twice daily on 07/03/25, 07/04/25, 07/05/25,07/06/25, 07/07/25 and 07/08/25 at 8:00AM. Resident #77 had no order listed on the MARs for Oxycontin ER 10mg one tablet twice daily for 7 days. Further review revealed Hydrocodone-Acetaminophen oral tablet 10-325mg one tablet every 6 hours as needed for pain was documented as administered one to 4 times per day for 19 days between 7/5/25 and 7/25/25. Resident #77's pain levels were documented 4 to 8 out of 10 (10 being the worst pain imaginable). Further review of Resident #77's July 2025 MAR revealed Oxycodone HCL oral tablet 5mg every 6 hours as needed for pain was documented as administered one to 3 times per day, for 17 days between 07/01/25 and 07/24/25. Pain levels were documented 4 to 9 out of a score of 10. Observation and interview on 07/23/25 at 6:55 AM, Resident #77 stated he was hit by a truck and was in the hospital for surgery to his leg. He had metal pins and a metal halo around his left leg. He stated he received Oxycodone twice a day and was due for the scheduled 9:00AM dose. He stated he could also have Hydrocodone-Acetaminophen oral tablet 10-325mg every 6 hours if he needed. He stated sometimes it may take 2.5 hours before he received pain meds after he asked for them. Then he later stated on the average it took one hour. He stated his pain was in his leg and his back and that his pain level was 8 out of 10. Observed RN-A administer Oxycodone IR 10mg and Hydrocodone-Acetaminophen 10-325mg one tablet at 8:00 AM prior to Resident #77 leaving for dialysis. In an interview on 07/25/25 at 9:30am, the DON stated the Oxycodone HCL was the same as the Oxycodone ER (Oxycontin). The DON stated she expected that the last person to administer the Oxycodone on 07/08/25 to Resident #77 should have removed it from the med cart, so there was no confusion. The DON confirmed the initials and stated MA-B administered the last dose on 07/08/25. The DON stated Resident #77 should not have been receiving Oxycodone ER 10mg after 07/08/25 without a physician's order. The DON stated the Oxycodone IR 10mg should have been started after 07/08/25. The DON stated continued administration of Oxycodone ER after 07/08/25 was a medication error that should not have happened and that it was probably due to a system failure. The DON stated the area of resident pain medication needed attention too, but her focus had been on behaviors since there were many residents with issues. The DON stated she expected nursing staff to match physician orders with the medication being administered and to follow the 5 rights of medication administration to prevent med errors. Record review of Resident #77's narcotic sheet for Oxycontin ER 10mg revealed a tablet was signed out on 07/08/25 at 8:00 AM. Record review of Resident #77's July MAR indicated Oxycodone HCL 10mg tablet was documented as administered by MA-B on 07/08/25 at 8:00 AM. On 07/26/25 at 9:20AM an attempt was made to contact MA-B via telephone. A voice message was left. No return call was received. In an interview on 07/26/25 at 12:35 PM, LVN-C stated she would check physician's orders in PCC and verify the medication card matched with the narcotic sheet. LVN-C stated she believed there may have been a change in order for Resident #77's oxycodone but was unsure of the date. LVN-C stated Oxycodone ER meant extended release, and IR meant immediate release and the danger of mixing them up could be overdose, or in some cases may not be effective or cause constipation. In an interview on 07/26/25 at 12:47 PM, RN-A stated she would confirm orders, check for the right resident, right medication, right dose and right time prior to administering medications. She stated administering the wrong dose of Oxycodone could place the resident at risk for lethargy, decreased vitals or decreased breathing. She stated since she was the charge nurse for the unit where Resident #77 resided, she was ultimately responsible to remove the Oxycodone ER 10mg (Oxycontin) when the order changed. She stated even prior to surgery Resident #77 was taking Hydrocodone/Acetaminophen for generalized pain and getting more Oxycodone could affect his mood as he had bouts where the meds did not really help him, and she would reposition the resident and if still in pain she would notify the MD. She stated receiving IR and ER together may affect his pain levels, the medication may work one day and not the next day. She stated she was in charge, and it should have not happened, and it was her responsibility to check medications. In a telephone interview on 07/26/25 at 1:20PM, RN-D stated she was familiar with Resident #77. RN-D confirmed initials on the Oxycontin ER 10mg sign out sheet. She stated she was aware the Oxycontin was a 7-day taper. She stated when she administered medication she would check the order, the last time it was received, ask the resident about his pain level and follow the 5 rights of medication administration, which included the right name, time and dosage. She stated Resident #77 was precise with his pain levels. She stated the risks of using multiple opioids depended on the resident's tolerance level and Resident #77 was taking opioids daily and had a high tolerance. She stated even before the Oxycodone he was taking Norco every 6 hours. She stated it didn't affect him much because he would tell her he was still in pain; she would call the doctor. She stated the difference between Oxycodone IR and ER was the IR was used for acute pain and ER for chronic pain. In an interview on 07/26/25 at 1:40 PM, MA-E stated her steps when she administers medications included to check the MAR and confirm the order on the blister packet: the dose and the route. MA-E stated oxycodone ER lasts longer than the IR. MA-E stated if the last tablet was given, the blister pack and narcotic sheet would be given to the DON. MA-E stated if it was the last dose of oxycodone to be given it would have been at night and she would not be able to give the blister pack to the DON and it should have been taken care of the next day. MA-E stated she did not communicate that to the next med aide MA-E stated she went on vacation. MA-E stated the Oxycodone IR was supposed to continue after the taper order. MA-E confirmed her initials on 7/8/25 at 8:00PM on the narcotic sheet for Oxycontin ER 10mg tablets. In an interview on 07/26/25 at 2:15PM, the Administrator stated the nurses would be responsible for calling the physician to get an order to discontinue a medication. The Administrator stated for anything clinical the ADON and DON would be responsible for reviewing the resident's pain management profile. The Administrator stated he did not know what happened with Resident #77's orders for oxycodone because he was not clinical and did not know how medication errors would impact residents. In a telephone interview on 07/26/25 at 2:30 PM, Resident #77's Physician-F stated there was a med error, there were two issues, and it was his fault when requesting the oxycodone. Physician-F stated he was responsible as there were two prescriptions, one for oxycodone IR and one for ER. He stated one of them was there to taper the drug down and he may have sent another order by mistake. Physician-F stated Resident #77 was back on Oxycodone ER twice daily and Hydrocodone/Acetaminophen for breakthrough pain. Physician-F stated the error with the Oxycodone would not have an adverse effect on Resident #77 since it was not working very well with his pain. When asked how addictive was Oxycodone, Physician-F stated Resident #77 did have pain and needed the medication, they must continue to monitor and taper when needed. In a telephone interview on 07/27/25 at 11:20AM, Physician-F stated the Oxycodone IR 10mg was supposed to be tapered then eventually Resident #77 would stay on Oxycodone ER 10mg. Physician-F stated if Oxycodone HCL was the prescription, the pharmacy will usually fill it as Oxycodone IR. Physician-F stated he expected the nurses/med aides to check the orders before giving a medication to ensure the ordered medication was the same on the medication blister pack. He stated the Oxycodone ER helped with his pain but not the Oxycodone IR. Physician-F stated switching prescribing systems in a few days, will catch any mistakes. Record review of the facility policy and procedure for Administering oral medications, revised October 2010, revealed in part: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation 1. Verify that there is a physician's medication order for the procedure.Steps in the Procedure.9.6. Check the label on the medication to confirm the medication name and dose with the MAR. Record review of the facility policy and procedure for Controlled Substances, revised November 2022, revealed in part: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #77) reviewed for pharmacy services.MA-B failed to administer Sevelamer (a phosphate binder used to control high phosphorus levels in residents on dialysis) as instructed on the pharmacy label.This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included:Record review of Resident #77's face sheet dated 07/23/25 revealed a [AGE] year-old male readmitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. His diagnoses included fracture of the shin bones of left and right leg, end stage renal disease (kidneys no longer function adequately requiring dialysis or transplant), Osteoarthritis (degeneration of joint cartilage and bone), anxiety, and dependence on renal dialysis.Record review of Resident #77's quarterly MDS dated [DATE] revealed a BIMs score of 14 out of 15 indicating intact cognition. Section I - Active Diagnoses included renal failure.Record review of Resident #77's undated care plan indicated a plan of care that included: Focus - Resident #77 was receiving dialysis for ESRD and at risk for symptoms including dry/itchy skin. Interventions included to give medications as ordered.Record review of Resident #77 active orders as of 07/23/25 revealed an order for Sevelamer HCL 800mg, take 3 tablets by mouth with meals for phosphorous control.Record review of Resident #77's July 2025 MAR/TAR indicated MA-B administered Sevelamer 800mg, 3 tablets on 07/23/25 at 8:00 AM. Further review revealed the MAR included give 800mg by mouth with meals for control of phosphorous level, take 3 tablets.Observation and interview on 07/23/25 at 6:55 AM, revealed Resident #77 was scratching his back and front of body using a back scratcher. His skin was dry. He stated he takes the phosphate binder Sevelamer with meals.Observation of medication pass on 07/23/25 at 7:45 AM, revealed MA-B administered Sevelamer Carbonate 800mg, three tablets to Resident #77. The pharmacy label instructions were to take with meals. MA-B did not administer with food.In a telephone interview on 7/25/25 at 9:40AM, RN-A was the nurse in charge of Resident #77 on 7/23/25 and was unaware that Resident #77 received the Sevelamer without food and that the orders should have been followed.A telephone interview was attempted on 07/26/25 at 9:00AM with MA-B. A message was left on voicemail to return surveyor call. Received no call back.Record review of the facility policy and procedure for Administering oral medications, revised October 2010, read in part: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation 1. Verify that there is a physician's medication order for the procedure.Steps in the Procedure.6. Check the label on the medication and confirm the medication name and dose with the MAR.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of four medication carts reviewed for storage of medications. RN-M failed to ensure the 200 Hall nurse medication cart was locked when unattended. This deficient practice could place residents at risk for loss of biologicals and place residents at risk of access to hazards.Findings included:In an observation and interview on 07/23/25 at 5:15 AM, revealed the 200 Hall Nurse Medication Cart was in the hallway positioned just outside the entrance to a resident's open room. The medication cart was unattended and unlocked, the lock was visibly not engaged. The medication cart contained a variety of medications labeled with Resident names and over-the-counter medications. The controlled substances were locked within the medication cart. RN-M was observed walking from one end of the hall towards the medication cart. RN-M stated she was called away to get something and forgot to lock the cart. RN-M stated the medication cart should be locked when unattended otherwise a confused resident could open the cart and take the medications. RN-M stated it was facility protocol to lock the cart before walking away and leaving the area.In an interview on 07/26/25 at 9:15 AM, the DON stated the nurse or medication aide assigned to the medication cart was responsible to make sure the cart is secure and not accessible to anyone who was not authorized access. The DON stated she would conduct a 1:1 in-service for medication storage.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 5 residents (Resident #112). -CNA-K failed to properly clean Resident #112 during incontinent care.-CNA-K failed to perform hand hygiene between glove changes.-CNA-K and LVN-L failed to put on a gown prior to incontinent care for Resident #112 who was in Enhanced Barrier Precaution (EBP). These failures could place residents at risk of urinary tract infections (UTI), discomfort, skin breakdown and decreased quality of life. Findings included: Record review of Resident #112's face sheet dated 07/25/25 revealed a [AGE] year-old admitted to the facility on [DATE]. His diagnoses included sepsis (a blood infection), anemia (reduced number of red blood cells), dementia, and contractures of the lower left leg. Record review of Resident #112's admission assessment effective date 07/16/25 indicated Resident #112 had no difficulty making himself understood and had no difficulty understanding others. Resident #112 had a urinary catheter and the resident or family reported recurrent urinary tract infections. Resident #112 required limited assistance of one person for bed mobility. Record review of Resident #112's undated care plan revealed the resident was at risk for decline in ADL functions, initiated on date 07/17/25. The goal was for the resident to be well dressed, groomed, clean, odor free and will not decline in ADL functioning over the next 90 days. Interventions included staff assistance for bed mobility, toileting and personal hygiene. The resident was at risk for skin breakdown and injury. The goal was for resident's skin to remain clean/dry, intact without evidence of breakdown over the next 90 days. Interventions included weekly assessment of skin and as needed and report any breakdown to MD/RP. The resident had a urinary catheter in place and was at risk for increased UTIs and skin breakdown. The goal was for the urinary catheter to remain patent and the resident to not develop incidents of UTIs and skin breakdown. Interventions included urinary catheter care as ordered. The resident had had wound to the tailbone and to the lower legs. The goal was for the resident's skin to remain clean/dry, healing with no further complications. Interventions included to perform treatment per MD order. Record review of Resident #112's July 2025 MAR/TAR revealed wound care to the sacrum was performed daily. Observation and interview of incontinent care on 07/22/25 at 3:29 PM revealed Resident #112 had a urinary catheter and a catheter anchor was in place for security. Resident #112 had a PICC line (peripherally inserted central catheter) to the inner upper right arm, the dressing was clean/dry/intact and dated 07/11. LVN-L was assisting CNA-K with the procedure. CNA-K and LVN-L washed their hands at the sink and put on clean gloves. CNA-K and LVN-L did not put on gowns. CNA-K and LVN-L opened Resident #112's brief, the resident had a large amount of soft-loose stool. CNA-K began by using cleansing wipes to remove all the stool around the groin and scrotum. CNA-K removed her used gloves, did not hand sanitize, put on clean gloves, then used clean wipes to cleanse the lower abdomen and penis. Resident #112 was rolled to his right side. CNA-K used clean wipes to clean all the stool from the rectum and buttocks. CNA-K removed her used gloves, did not hand sanitize, then put on clean gloves. The resident had a small wound to the sacrum. CNA-K applied barrier cream to the surrounding skin. CNA-K removed the used gloves, did not wash her hands and put on clean gloves then positioned the clean brief, secured the brief and covered the resident with bed sheets. CNA-K and LVN-L removed their gloves, washed theirs hands and gathered the garbage bags to remove from the room. LVN-L stated she forgot to put on a gown because she was so excited to do the nailcare just prior to incontinent care. LVN-L stated the resident was to be in EBP for the wounds, PICC line and indwelling urinary catheter and the reason was so not to introduce any new infections to the resident. In an interview on 7/22/25 at 3:50PM, CNA-K stated EBP was for residents with open wounds and urinary catheters CNA-K stated she should have put on a gown as well as gloves prior to starting the procedure but she was nervous and forgot. CNA-K stated she should have started cleaning the lower abdomen, then the groin and penis area first but she did not because she wanted to get all the stool cleaned up first. She stated she was taught to clean from penis first it should have been cleaned first because she should not have gone from dirty area to clean, and the rationale was to help prevent infections and cross-contamination. CNA-K stated she should have removed dirty used gloves and hand sanitization or wash hands, but she was nervous and forgot. CNA-K stated the risk to the resident was cross-contamination and infection. In an interview on 7/25/25 at 3:15 PM, the DON stated a gown, and gloves were to be worn during incontinent care for a resident on EBP in order to help prevent MDRO infection (multidrug-resistant organisms) for residents who have a urinary catheter, chronic wounds and residents who have had tracheostomy(an external breathing tube) for greater than 30 days because the tracheostomy would need to be protected. The DON stated for incontinent care for the male resident, she expected to start with the cleanest part and remove the majority of soilage if incontinent of bowel. The DON stated dirty gloves should be removed and hand hygiene performed prior to putting on new gloves to prevent cross-contamination and to make sure bacteria is not introduced to the urethra or any wounds from the dirty gloves. The DON stated it was the responsibility of the infection preventionist and the DON for ensuring the staff were following infection control practices. Record review of the facility policy and procedure for Infection Prevention and Control Program updated on 04/2025 read in part: .2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection. Record review of the facility policy and procedure for Perineal Care revised in February 2018, revealed in part: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.For a male resident:.b. Cleanse perineal area starting with urethra and working outward. C. if the resident has an indwelling catheter, gently cleanse the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.f. continue to cleanse the perineal area including the penis, scrotum, and inner thighs.j. ask the resident to turn to his side.l. Cleanse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. 8. Discard disposable items into designated containers. 9. Remove gloves and discard into designated container. 10. Wash and dry your hands thoroughly. 11. Reposition the bed covers. Make the resident comfortable.14. Wash and dry your hands thoroughly.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns.The facility failed to properly dispose of waste in the appropriate receptacles. Two red cylindrical 32-gallon containers with white letters on the outside of it reading Infectious Waste: Biohazard containing unknown waste were located outside of the facility. This deficient practice could place residents, staff, and the public at risk of being exposed to potentially hazardous waste.The findings included: Observation on 07/22/2025 at 1:51 PM revealed 1 red, cylindrical, 32-gallon container without a lid, and with white letters on the outside of it reading Infectious Waste: Biohazard was located outside of the facility near the generator. The container held red bags of unknown origin and water. The container appeared to have been outside exposed to the weather for some time as some of the red bags were deteriorated. Observation on 07/22/2025 at 1:53 PM revealed 1 red, cylindrical, 32-gallon container without a lid, and with white letters on the outside of it reading Infectious Waste: Biohazard located outside of the facility near a storage shed. The container had various items of trash along with red biohazard bags. During an Interview on 07/24/2025 10:30 AM with the ADON/IP, she reported when asked about the facility process regarding use of the red biohazard bags, they only used the bags for residents in isolation. They kept the biohazard box with the red bag liner in the resident's room if they were on isolation. Once the bag needed to be removed, they closed the box lid and removed the box from the room. The box was taken to the Medical Waste room. They had a contract service that picked up the boxes from the medical waste room. The boxes and bags were not taken outside the building by staff. She was not aware of any biohazard containers outside of the building and said there was no reason to take it outside when it was picked up by the service inside the building. They don't use red garbage bins for disposal, and she did not know why there were red biohazard containers outside the building.Observation on 7/24/25 at 10:33 AM of the Medical Waste room revealed an unlocked closet with Medical Waste noted on the door. The room contained biohazard boxes and red biohazard bags. There were approximately 30 folded, unused boxes, 3 boxes filled and closed, and 1 box, lined with a red bag was open for use.During an interview on 07/25/2025 11:37 AM with the Administrator about biohazard containers located outside the building, he reported he did not know what was inside of them or how long they had been there. They had been emptied and discarded. During an interview on 07/25/2025 11:40am with the Maintenance Director, he reported he did not know how long the containers were there, probably for years. He did not know what was in the containers and reported that they were not used for biohazard disposal. The bags were disintegrating from being outside and they were not able to tell what the contents had been. The red containers have been disposed of in the dumpster.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 2 of 3 Halls (100 and 200 Halls) reviewed for environmental concerns. 1. Overhead light was not illuminating in the bathroom of room [ROOM NUMBER]. 2. Baseboard coming off the wall in rooms 118, 201, 3. Broken sheet rack in rooms 113, 219, 206 4. Peeling paint on the wall in rooms 103, 120, 5. Floor tile lifting in room [ROOM NUMBER] 6. Strong urine/feces odor in room [ROOM NUMBER], 116 and 120. In 116 and 120 brown substance that looked like feces the toilet and floor. This deficient practice could affect residents who resided in rooms on hall 100 and hall 200 by causing the residents to live in an environment that would not improve their quality of life. Findings Included: Observation on 3/27/2025 between 9:30am and 10:30am revealed the following. In room [ROOM NUMBER] the light in the bathroom was not illuminating. In rooms [ROOM NUMBERS] the baseboard coming off the wall. 201 window blinds were broken. In rooms 113, 219 and 206 revealed broken sheet rack. In rooms [ROOM NUMBERS] has peeling paint on the wall. In room [ROOM NUMBER] there was a hole under the window where the tape was not affixed to the wall and a hole in the sheet rack near the entrance door. There was an electric cord plug in the wall across the floor to bed A. Rooms 112,116 and 120 had strong offensive urine/feces odor. In room [ROOM NUMBER] and 120 the toilet bowl, seat and floor had brown stains and smear that looked and smelled like feces. In rooms [ROOM NUMBERS] the floor had an accumulation of brown stains on it. Interview on 3/27/2025 at 9:35am. with an unidentified resident revealed that there was no light in the bathroom of113. Interview on 3/27/2025 at 1:25pm with the Maintenance Supervisor revealed that he was not aware of the light not working in room113. He said maybe it was just the bulb that needed to be changed. He said he was going to check the bathroom I 13 and change the bulb. He said he had just gotten the position as maintenance supervisor, and he was going to address all concerns brought to him. He said there was a book on all stations and concerns were documented in them. He said each morning he would check the books and see what needed to be done and try to address them as quickly as possible. In an interview on 3/27/2025 at 4:00pm the Administrator said Maintenance Supervisor said he had just taken the position as supervisor, and he was going to hire an assistant for him. He said he was going to address the concerns brought to him. Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part . Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible. Policy Interpretation and Implementation 1. Staff provide person-centered care that emphasizes the resident comfort, independence and personal needs preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. cleanliness and order. b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting. e. Pleasant neutral scents.

Based on observation, interview and record review, the facility failed to establish an infection prevention and control program that included handling of soiled linen, and patient care equipment as well as to help prevent the development of communicable diseases and infections, on 2 of 3 halls (Hall 100 and Hall 200) observed for infection control. CNA D and CNA E were observed taking dirty linen and soiled brief to the trash can across the hallway and they were not in clear trash bag. Personal care basins and bed pans were on the bathroom floor not labeled with resident's name and not in plastic bags. These failures have the potential to affect all residents by placing them at risk of infections and diminishing quality of life. Findings included: Observation on 3/27/2025 between 9:30am and 10:30am revealed the following: In room [ROOM NUMBER], 118, 112, 218, 219, 209 and 208 personal care wash basins on the floor in the bathroom with no name and two residents share the rooms. In room [ROOM NUMBER] was a urinal and a bed pan on the floor in the bathroom not in a plastic bag with no name and two residents share the room. Observation on 3/27/2025 at 4:00pm revealed CNA D leaving room [ROOM NUMBER] with soiled brief with feces not in a clear bag to the trash can across the hallway. Further observation at that time revealed CNA E, at the doorway with soiled towels heading to the trash cannot in a bag. At that point the Surveyor asked what was going on and she stopped, and CNA D brought her a clear plastic bag and CNA E put the soiled linen in the bag and took it to the dirty barrel. In an interview on 3/27/2025 at 4:00pm with CNA E she said she was in training. She said that they should not be walking with the dirty linen and soiled brief. She said they should place the soiled linen and brief into plain plastic bags to dispose of them. In an interview on 3/27/2025 at 4:05pm with CNA D she said she should have clear plastic bags in the room during incontinent care. She said having to walk across the hallway with the soiled brief could cause waste to drop on the floor which could cause infection. She said she was in-serviced on infection control, and she should have bags in the room when incontinent was being provided. In an interview on 3/27/2025 at 4:29pm the DON said nursing staff were in-serviced on infection control and ensuring that soiled briefs were in plain plastic bags and disposed in the trash bins and linen be placed in plain plastic bags and placed in the dirty barrel. She said resident personal care basins, urinal, and bed pans should be in clear plastic bags and the names of the residents be written on them. She said this could cause infection when using resident care equipment for multiple residents. She said she was going to immediately start in-servicing the staff. Record review of the facility policy on Standard Precautions dated 2/2023 read in part . Policy Statement Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation 5. Resident-Care Equipment a. Handle used resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments. b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded. 7. Linen a. Handle, transport, and process used linen soiled with blood, body fluids, secretions, excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environments. Record review of the undated facility's Policies and Practices - Infection Control read in part . Policy Statement This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility. b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; f. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment.

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so the facility was free of pests on two of three halls (Hall 100 and Hall 200) reviewed for pest control. The facility failed to ensure the building was free of roaches and gnats. This failure could place residents at risk of infection, skin irritation, allergies, and unsanitary living conditions which could result in a decline in health and well-being. Finding included: Observation during the survey process on 3/27/2025 between 9:30am and 10:30am revealed the following: In room [ROOM NUMBER] there were gnats flying in the room. In room [ROOM NUMBER] there was a live roach crawling on the resident's over bed table and there was a dead roach on the floor near the resident's bedside to the closet area. In room [ROOM NUMBER] was a roach crawling in the corner near the closet of bed A. In interviews on 3/27/2025 between 9:30 am and 10:30am with 2 unidentified residents revealed that roaches were always in their rooms. They said they would spray the roaches, but the roaches would always come back. One resident said he tried to follow the rules but sometimes he would get his own spray and spray his room to get rid of the roaches. In an interview on 3/27/2024 at 10:50am Resident #1 said roaches were always in her room. She said they usually spray her room but there were still roaches. She said the last time she saw a roach was the morning of the survey crawling on her overbed table. Observation on 3/27/2025 at 10:52am the resident pointed a live roach crawling on her overbed table to the surveyor. The roach was crawling from one end of the overbed table to the other. It was pointed out to the CNA who was working the floor. At that point the CNA said she would take care of it. In an interview on 3/27/2025 at 1:25pm with the Maintenance Supervisor he said the pest control company was in the building two days ago. He said they were spraying for roaches. He said they were coming once a month, but they were now set up for them to come once a week for four weeks and then back to monthly spraying. In an interview with the Administrator on 3/27/2025 at 4:10pm regarding pest control issues in the facility, he said the pest control company was in the building a few days ago. He said they used to come monthly but they just changed the contract to once a week for four weeks and then back to monthly visits. Record review of the grievance log for March 2025 revealed that on 3/24/2025 insects were observed on the resident's plate. No location was documented on the grievance log. Record review of the pest control receipt dated 1/10/2025 revealed the pest control company was in the building on 1/16/2025, 2/25/2025, 3/14/2025 and 3/25/2025 to treat spiders, roaches, and ants. They treated patient and guest rooms for roaches, spiders and ants and on 3/25/2024 the kitchen was treated for roaches and fumigated, and resident rooms and office treated for roaches. Further record review revealed the rooms that were identified with roaches and gnats were not included on the list of rooms that were treated on 3/25/3035. Record review of the undated pest control policy and procedures read in part . Policy Statement: Our facility shall maintain an effective pest control program. 1. This facility has an ongoing pest control program to ensure that the building is kept free of insect and rodent.

The facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was given as ordered by the physician. This failure could place residents who received medications at risk of not getting their medications as ordered which could result in resident not receiving the therapeutic benefits of the medication for blood pressure which could result in decreased quality of life. Findings included. Resident #2 Record review of Resident 2#'s admission face sheet dated 05/15/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses diagnosis included essential hypertension (high blood pressure). Record review of Resident#2's MDS dated [DATE] revealed a BIMS score of 08, indicating Resident #2's cognitive skills for decision making was moderately impaired. Record review of Resident #2's physician's order summary report for May 2024 revealed an order dated 5/6/2024 for Metoprolol Tartrate Oral Tablet 25mg give 1 tablet by mouth every 12 hours for Hypertension. Hold for SBP <110 or DBP< 70 or HR < 60. Record review of Resident #2's MARs revealed Metoprolol Tartrate Oral Tablet 25mg the medication was administered on the following date and time: * 5/07/2024 at 9:00pm when the blood pressure was 83/51, on *5/09/2024 at 9:00 PM when SBP was 105/67, and on *5/10/2024 at 9:00 PM when SBP was 105/67. Further record review of the MARs revealed on 05/09/2024 and 05/10/2024 were given by LVN C. In an observation and interview on 05/15/2024 at 10 :55 Resident #2 was observed in bed. She was alert and oriented and could make their needs known. She was clean and well-groomed with no offensive odor. Resident was able to voice her needs. Interview with Resident #2 revealed she had no problems getting her medications. In an interview on 5/16/2024 at 10:00am with LVN C, she said she was not the one who gave Resident #2 her 9:00pm medication. She said she usually checked the resident blood pressure before her medication was administered. She said if her blood pressure was in the parameter that it should be held, she would not give it. She said she would hold the blood pressure medication. She said she it was difficult to say when the medication was held and when it was documented as given. She said if medications were not given it should be documented as not given and the reason why it was not given. In an interview on 05/15/2024 at 3:00pm the DON said her expectations was the orders were followed and when the vital signs were within the parameters the medications should not be given. She said she was going to in-service the staff and supervise the blood pressure medication administration. In an interview on 5/16/2024 at 3:20pm with LVN B she said she was sure she held the medications because she knew that Resident #2's blood pressure sometimes ran low. She said she might have documented incorrectly. She said that if the blood was already low and she gave the medication it would bring the blood pressure lower, and this would cause the resident to get dizzy and could get sick. Further interview with the DON on 5/16/2024 at 3:45pm she said Resident #2's blood pressure could drop when the medication that was to be held was given. That could cause her to become dizzy and fall and injury could occur. The DON said Resident #2's blood pressure medication has parameters and once the blood pressure was checked, and the blood pressure was in the parameter if it was ordered to be held, then they should not have given the medication. She said she was going to in-service the staff regarding blood pressure parameters, and she was going to audit blood pressure medication to ensure they have parameters in place, and staff were following the parameters. In an interview on 5/16/2024 at 4:00pm, the Administrator stated the expectations were that medications were given according to the physician's orders. He said he would have to ensure that staff were in-serviced. Record review of the facility policy titled Administering Oral Medication undated read in part . Purpose: To provide guidelines for safe administration of oral medications. Preparation. Verify that there is a physician's order for this procedure. Steps in the Procedure . 13. Perform any pre-administration assessment Medications are prepared, administered, and recorded by the same authorized medical/licensed staff. Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: 1. Food items were not sealed and/or not dated in the facility pantry . 2. One can of canned food was dented and stored with the non-dented food cans . These deficient practices could place 89 residents who received meals from the main kitchen at risk for food borne illness. Findings included: 1. Observation in the pantry of the food items on 04/30/24 at 08:32 am revealed one 16 oz bag of tortilla chips was opened, not sealed, not dated. Observation in the pantry of the food items on 04/30/24 at 08:33 am revealed one 80 oz bag of instant oatmeal was dated, not sealed. Interview with the Dietary Manager on 4/30/24 at 2:08 pm she said the food items that were not sealed should have either been destroyed or their entire contents should have been used because of the small amount of food that was in the bags. She said all kitchen staff were responsible for checking if food is sealed and dated in the pantry. She said she would go behind kitchen staff and double check food items in the pantry. She said the risk to the resident would be food poisoning. Interview with the Dietary Aide on 4/30/24 at 2:14 pm, she said she has worked at the facility for 8 months. She said kitchen staff were supposed to store leftover food in Ziploc bags and date. She said everyone in the kitchen was responsible for labeling and dating opened food items. She said the risk to the resident could make them sick. Interview with the Dietary [NAME] on 4/30/24 at 2:22 pm she said she has worked at the facility for 1 year and 5 months. She said the food items in the pantry were supposed to be stored in a Ziploc bag and dated. She said everyone in the kitchen was responsible for labeling and dating food items and the next shift would check for food items in case any were missed by the previous shift. She said the risk to the resident if food items were not sealed or dated would cause the resident to get sick. 2. Observation in the pantry of the non-dented cans on 04/30/24 at 08:35 AM revealed one 104 oz can of apples in water had a small dent on the bottom of the seam. Interview with the Dietary Manager on 4/30/24 at 8:36 am confirmed the dented can of apples should have been stored with the dented cans. Interview with the Dietary Manager on 4/30/24 at 2:09 pm, she said the dented cans should be stored on a separate shelf away from the non-dented cans. She said everyone in the kitchen was responsible for checking dented cans and she would go behind to double check. She said the risk to the resident would be exposure to botulism. Interview with the Dietary Aide on 4/30/24 at 2:15 pm, she said dented cans should be stored away from regular cans in their own designated area. She said kitchen staff go behind each other to double check for dented cans. She said the risk to the resident would cause them to get sick. Interview with the Dietary [NAME] on 4/30/24 at 2:23 pm, she said the dented cans should be stored on a separate shelf. She said everyone in the kitchen should check for dented cans. She said each shift goes behind the previous shift and checked for dented cans. She said the risk to the resident would cause them to get sick. Record review of the facility's Food Receiving and Storage undated policy under section 13e read in part . opened containers must be dated with use by date and sealed or covered during storage . Record review of the U.S. Food and Drug Administration dated 1/18/23 under Chapter 3 read in part . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act .rusted and dented cans may also present a serious potential hazard .

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #44) reviewed for medication administration were free of significant medication errors. MA L administered Doxazosin Tablet 4mg and Amiodarone HCl Tablet 200mg (medications used to treat high blood pressure), while Resident #44 was assessed with blood pressure lower than the physician recommended parameters for administering the medications. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. Findings included: Review of Resident #44's face sheet, dated 05/02/2024, revealed that the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart failure (condition that occurs when high blood pressure damages the heart and reduces its ability to pump blood effectively). Review of Resident #44's quarterly MDS assessment, dated 03/25/24, revealed a BIMS score of 15 (an intact cognitive response. Review of Resident #44's May/2024 active Physician Order Summary revealed the following orders: Amiodarone HCl Tablet 200 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold For SBP<110 DBP<60 Doxazosin Mesylate Tablet 4 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP<110 DBP<60 Observation on 05/02/2024 at 8:15am revealed MA L was observed obtaining Resident #44's blood pressure with a blood pressure reading of 100/65. MA L proceed by administering the medications and verbalizing to Resident #44 that he was receiving all morning medications including blood pressure medications. Review of Resident #44's May/2024 Medication Administration Record (MAR) revealed that MA L administered Doxazosin Tablet 4mg and Amiodarone HCI Tablet 200mg. Each of the medications were administered outside of the physician indicated parameters on 05/02/2024. Resident #44's systolic blood pressure was documented by MA L with a systolic blood pressure of 100 and a diastolic blood pressure of a 65. Interview with MA L on 05/02/2024 at 8:20am, MA L denied administering Resident #44's blood pressure medication, stated that she had discarded the medication in Resident #44's designated trash bin in his room. There was no observation of the referenced discard of the medications. Interview and observation with ADON on 05/02/2024 at 8:30am, ADON was notified of the surveyor's observation of MA L administering blood pressure medication outside of the indicated parameters; and MA L denial of administering the medications. ADON proceeded to assess Resident #44 for adverse side effects. The ADON stated that MA L was not able to produce the pills and that the medication was not in the trash bin as alleged by MA L. The ADON stated that MA L later disclosed that she had administered the medications. The ADON stated that the physician was notified. MA L was removed from the floor and provided in-service and educated on medication administration. Interview on 05/02/2024 at 9:30AM with MA L, MA L stated that if blood pressure medication is administered outside of the recommended parameters, the resident's blood pressure could drop too low causing the resident to have severe complications. MA L stated that staff administering the medications was responsible for ensuring that a medication was given within recommended parameters. MA L stated if blood pressure medication was given out of recommended parameters the medication could cause the blood pressure to become too elevated or too low. Observation on 05/02/2024 at 9:33 AM revealed Resident #44 was observed sitting in bed watching television. Resident reported that he was feeling well. Interview on 05/02/2024 at 1:22 PM with the DON, stated that MA L later disclosed that she had administered the medications. The DON stated that the physician was notified. MA L was removed from the floor and provided in-service and educated on medication administration. The DON stated medication should be held if the vitals were out of parameters. The DON stated the medication aide should have notified the nurse and the nurse would have notified the doctor that the medication was not administered because the resident's vitals were out of parameters. The DON stated that the purpose of the recommended parameters for the medication is to ensure that the resident remains in a safe blood pressure range identified for the resident. Review of the facility's Medication Administration policy, not dated, reflected: .Medications must be administered in accordance with the written orders of the physician's order.

Based on interview and record review, the facility failed to ensure the written policies and procedure to prevent abuse were implemented for 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4), in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. - The facility failed to develop and implement interventions to prevent Resident #1's aggression and abuse of Residents #3 and #4. An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level. These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. Findings included : Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood. Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis. Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs . Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1. Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents . Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma. Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate . Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident . Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation . Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient. Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident . Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia. Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs . Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident. Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER. Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B . Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days. Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023. In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people . In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day. In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable. In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice. In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. Record review of facility's policy on Abuse Investigation and Reporting reflected Administrator's duty to, .ensure any further potential abuse . is prevented. An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM. On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY F 600 On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance. On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance. Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse. Action: o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated . Monitoring : In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024. Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023. In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression. In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to. In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented. In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.

Based on interview and record review, the facility failed to ensure 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4) were kept free form abuse, in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level. These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. Findings included : Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood. Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis. Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs . Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1. Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents . Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma. Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate . Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident . Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation . Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient. Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident . Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia. Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs . Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident. Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER. Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B . Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days. Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023. In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people . In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day. In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable. In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice. In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. Record review of facility's policy on Abuse Investigation and Reporting reflected Administrator's duty to, .ensure any further potential abuse . is prevented. An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM. On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY F 600 On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance. On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance. Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse. Action: o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated . Monitoring : In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024. Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023. In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression. In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to. In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented. In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.

Based on interview and record review, the facility failed to revise the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 1 (Resident #1) of 6 residents reviewed for care plans in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. - The facility failed to develop and implement interventions to prevent Resident #1's aggression and abuse of Residents #3 and #4. An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level. These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. Findings included : Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood. Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis. Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs . Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1. Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents . Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma. Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate . Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident . Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation . Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient. Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident . Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia. Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs . Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident. Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER. Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B . Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days. Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023. In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people . In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day. In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable. In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice. In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. Record review of facility's policy on Abuse Investigation and Reporting, not dated, reflected Administrator's duty to, .ensure any further potential abuse . is prevented. Record review of facility's policy on Care Plans, not dated, reflected, .The comprehensive, person-centered care plan will: a)include measureable objectives and timeframes b) describe the [NAME] that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM. On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY F 600 On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance. On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance. Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse. Action: o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated . Monitoring : In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024. Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023. In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression. In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to. In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented. In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.

Based onobservation, interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. - The facility failed to prevent Resident #1's healed sacrum pressure ulcer from reopening and deteriorated to completely covered with necrotic (dead) tissue in the wound. This failure could place residents at risk for new development or worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses were, encephalopathy (any disease of the brain that alters brain function), dementia (impaired ability to remember, think, that interferes with everyday activities), dysphagia, and respiratory failure (when lungs cannot get enough oxygen into the blood). Record review of Resident #1's 5-day MDS dated [DATE] revealed section C1000 cognitive skills read severely impaired. Further review revealed the resident needed extensive to total care with all ADL with one to two people assist. It also revealed the resident was incontinent of bowel and bladder. Resident #1 was at risk of developing pressure ulcers. Interventions: Pressure reducing device for the bed and turning/repositioning. Record review of Resident #1's care plan dated 02/08/23 revealed Resident #1 developed facility acquired unstageable pressure ulcer on sacrum which measured: -02/08/23, 7. 5 x 7 cm -02/10/23, 6.01 x 9.9 cm -02/17/23, 6.00 x 9.9 cm Interventions: treatment per MD orders, measure weekly, support air mattress, and turning and repositioning. Record review of Resident #1's admission skin assessment dated [DATE] revealed resident had pink fragile skin on sacrum and ischium. Record review of Resident #1's Braden scale for predicting pressure sore risk dated 02/01/23 revealed the resident scored 10 which indicated the resident was high risk of developing pressure sores. Record review of Resident # 1's Braden scale for predicting pressure sore risk dated 02/08/23 revealed the resident scored 13 which indicated the resident was moderate risk of developing pressure sores. Record review of Resident #1's wound weekly observation tool dated 02/08/23 revealed the resident developed 100% necrotic pressure ulcer on his sacrum and it measured 7.5 x 7.0 cm. Record review of the wound care doctor's initial exam dated 02/10/23 for the sacrum wound read unstable pressure injury obscured full - thickness skin and tissue loss and had 100% necrotic tissue. It was measured at 6.01 x 9.9x 0 cm. Record review of the wound care doctor's initial exam dated 02/10/23 for the sacrum wound read unstable pressure injury obscured full - thickness skin and tissue loss and had 30% slough /70% necrotic tissue. It was measured at 6.0 x 9.9 cm. treatment was clean with normal saline apply Santyl, calcium alginate and cover with dry dressing. Record review of Resident #1's shower sheet dated 02/03/23, and 02/06/23 revealed the resident sacrum was intact. Reocrd review of Resident #1's shower sheet dated 02/08/23 revealed the resident had circle drawn on the sacrum area on the paper. Record review of the TAR (Treatment administration record) dated February 2023 revealed apply zinc ointment to the sacrum every shift and as needed. Every shift for incontinent, prophylaxis. Discontinued 02/22/23 at 1443. It also revealed the nurses signed off on the TAR on day, evening, and night shifts. Observation of wound care on 02/22/23 at 1:07 p.m., during Resident #1's wound care on the sacrum, revealed the resident had an unstageable wound on his sacrum. The wound measured 6.5 cm x10.3 cm. It appeared to contain black Eschar and some yellow slough. Resident #1 was lying on the right side before treatment. Resident #1 was turned to his right side. Observation and Interview on 02/22/23 at 1:20 p.m. during Resident#1's wound care, the DON said the wound bed was primarily covered with black necrotic tissue and some yellow slough at 100%. He said he had not seen the wound before now. Interview on 02/22/23 at 1:45 pm, the Wound Care Nurse said Resident #1 was admitted to the facility on [DATE], and he developed a wound on the sacrum on 02/08/23. She said when she was notified about the wound, it was already unstageable and 100 % necrotic. The Wound Care Nurse said when the resident was admitted , she did a skin assessment, and he did have a pink and healed wound on the sacrum. The Wound Care Nurse said the nurse does the weekly skin assessment, and his assessment was due on Friday on 10 pm to 6 am shift. She said she checked the shower sheets every day, and there was no documentation of any skin issues on Resident #1's shower sheets. She said the first treatment she did was Santyl and alginate on 02/08/23, and it was changed to betadine and dry dressing on 02/10/23 when the Wound Care Doctor first saw the wound on Resident #1's sacrum. The doctor changed it back to Santyl and alginate on 02/17/23. Surveyor Requested for Braden scale, initial and weekly skin assessment, and wound care training, which she said was done by a wound company. She said the facility does Braden scale to see if the resident is at risk, and she would put an intervention in place. She said the initial Braden scale at admission showed Resident #1 was at high risk for pressure sores, and the shower sheet should have alerted any change in skin condition. The Wound Care Nurse said that was why she ordered zinc ointment every shift and as needed, and it was on the nurse's MAR. She said the nurses signed off on the MAR every day until today. The Wound Care Nurse said the nurses should have observed changes on the sacrum when they applied the ointment and notified her or called the doctor before the area became unstageable. She said somebody dropped the ball, and it is what it is and she indicated that they would treat what the resident had now. The Wound Care Nurse said when she was made aware of the wound, it was already 100 % necrotic. She said she had not notified the dietitian about Resident #1 wound, and she should have informed the dietitian by now. Interview on 02/22/23 at 2:20 p.m. ADON said she had not looked at Resident #1's wound. She said the Wound Care Doctor and the Wound Care Nurse do the wound assessment and treatment. She said the admission nurse does the skin assessment, and Braden was done on admission, and it is done weekly for four weeks, then quarterly. The ADON said if the resident came with a wound, then the resident was turned/repositioned every two hours and put on an air mattress. She said she did not know the facility protocol for monitoring residents to prevent wounds because she did not do wound care. She said the question should be directed to the Wound Care Nurse. Interview on 02/22/23 at 4:57 p.m., the Administrator said Resident #1 sacrum area was pink and fragile on admission. She said the Wound Care Nurse did a skin assessment on 02/08/23, which was how she found out the resident had a sacral wound. The Administrator said Resident #1 could develop a wound in one day, and there was no issue with his sacrum, which was why there was no documentation on the sacrum. She said in a nursing home, they do problem charting. She did not respond when asked if the nurses and aides did not see any change in Resident #1's skin before the sacral area turned from pick to necrosis. The Surveyor requested in-service wound assessment for all the nurses who worked with Resident #1 for the first week who applied zinc oxide on his sacrum and the aides who worked with the resident for the first seven days, and any training or in-service on skin monitoring and assessment training. Interview on 02/23/23 at 8:15 a.m., Resident #1's PCP, he said he became aware of Resident #1's wound on the sacrum this week, but the Wound Care Doctor was involved in the resident's care. He said the resident had comorbidities that could contribute to wound development and healing. He was asked what the nurses expected to do when they knew a resident was at risk of developing pressure ulcers and the area was already compromised. He said he understood what you are asking, but you should direct the question to the Wound Doctor because he was involved in the resident care . Interview on 02/23/23 at 8:28 a.m., the DON did not respond when asked how Resident#1, who had no wound on his sacrum, deteriorated to unstageable with 100% necroses before treatment was started. DON said the resident skin was monitored during the weekly skin assessment, and there was no documentation on the shower sheets of any skin issues until 02/08/23. Then the Administrator said they would treat the wound if they had an order. She said if zinc oxide was ordered and the nurses signed off on the TAR, the treatment was done. When asked when the nurses applied the zinc oxide to the sacrum, did the nurses assess the area and observe any change on the sacrum before it turned necrotic? She asked why you asked about what happened on February 8, today, February 23. She further said that the facility found out about the wound, which is being treated, and the wound care doctor saw the resident weekly. DON said the wound care company trained the Wound Care Nurse. He said the facility monitored Resident #1's skin when the nurse did a weekly skin assessment, and the resident was turned and repositioned every two hours. Interview on 02/23/23 at 8:37 a.m., the Wound Care Nurse said an outside wound care company trained her on how to provide wound care, and she had a skill check-off done by the facility. She said that Resident #1's the sacrum was not open but pink and fragile. The Wound Care Nurse said she expected the nurses to treat the resident and call her if there was any change in the skin or call the doctor. She said the nurses did not tell her that the area was changing color. The Wound Care Nurse said the ADON told her on 02/08/23 that resident #1 wound looked different because somebody told her. She said that no Nurse Manager makes rounds to see the wounds. She said the wound was moist black necroses at 100% but was not draining. She said she called the resident's PCP, spoke to the NP, who gave the order to use Santyl, and had the wound doctor look at it. She said she notified the wound doctor when he came to see Resident #1 on 02/10/23. She said the Wound Care Doctor measured it and said to apply betadine. Interview on 02/23/23 at 8:53 a.m., the ADON said a CNA told her that there was an open spot on the resident sacrum, and she told the Wound Care Nurse. However, she said was not sure which CNA, because the facility uses a lot of agency staff, and she cannot remember who told her. Interview on 02/23/23 at 9:08 a.m., CNA A said Resident #1's sacrum was clear, and there was no redness or open area (02/05/23) when he worked with the resident, and he said Resident #1 did not have any nurse apply any cream on his bottom. CNA A said he did not use a protective barrier on his bottom. Observation and attempted Interview on 02/23/23/ at 9:05 a.m. revealed Resident #1 was lying on the right side facing the window. Resident #1 was not able to verbalize if he had a wound on his sacrum or if any treatment was done on his sacrum. Interview on 02/23/23 at 9:17 a.m., LVN B said she saw the area on Resident #1 sacrum with the wound care nurse on 02/02/22. LVN B said the sacrum was pink to red. She said she believed the aides were putting zinc on Resident #1's sacrum. She said she did not apply any cream on his sacrum. Instead, she said she would ask the aides to reposition the resident. She said she was unaware that the resident had developed a wound on the sacrum. She said she only looked at the site again once the wound care nurse started treating Resident #1. Interview on 02/23/23 at 11:00 a.m., LVN B said she signed the treatment for zinc to the sacrum, but she gave the cream to the aide to apply on Resident #1 sacrum, and she believed the aide would have told her if the resident had any open wound. LVN B said if she had applied the cream herself, she would have seen if the area had changed, and she would have notified the doctor and the wound care nurse earlier before it became necrotic. Observation on 02/23/23 at 11:05 p.m., resident was on his back. Interview on 02/23/23 at 12:49 p.m., the Wound care doctor said wound color could change within 24 hours, and if different nurses were caring for Resident #1's wound, they could interpret the different shades of the skin differently. He said he told the Wound Care Nurse if she found any change in the resident's wound, she should send a picture, and they could talk about it through zoom instead of waiting until he came to make regular rounds. He said the first time he saw the wound on Resident #1's sacrum was on 02/10/23. He said Resident #1 had comorbidities and would affect the development and healing of the wound. Interview on 02/23/23 at 1:36 p.m. LVN C said he gave the cream to the aides to apply to Resident #1 sacrum, and he knew the aide would tell him if Resident #1 had any open area on his sacrum. He said the aides should apply zinc oxide on the Resident's sacrum, and if the Resident had an actual wound, the Wound Care Nurse would treat the resident. LVN C said he did not look at the resident sacrum because they do weekly skin assessments, and he would look at the resident's skin during the skin assessment. LVN C was asked why he signed the TAR when the aide applied the cream. LVN C said it was what the nurses do if the Resident does not have a wound. When asked if he had applied the cream on Resident #1, would he have noticed the change on the Resident's sacrum, he did not respond. He said he had skills check off, which had a section about skin assessment. Record review of the facility policy on skin assessment monitoring guidelines dated 10/2021 read, . all residents will be assessed upon admission . to identify risk factors that may lead to impaired skin integrity . nursing personnel will begin implementation of intervention within 24 hours and should complete all intervention within 72 hours . all residents receiving a Braden scale of 18 will be considered at risk for developing a pressure sore Record review of the undated facility policy on wound monitoring guidelines read, . a resident who has developed or is admitted with wound will receive necessary treatment and services to promote healing . prevent new wound from developing .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 14 residents (Resident #1) reviewed for accidents. CNA A failed to request assistance when she provided incontinent care to Resident #1, who was cognitively impaired, had contracted hands/fingers, and was a two-person assist for bed mobility, and resulted in a fall with injury. This failure placed residents who were dependent on staff for ADLs at risk of serious physical/emotional injury, pain, and death from falls. Findings include: 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 [CONDITION(S)] (a common and potentially serious bacterial skin infection) of the abdominal wall, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), [CONDITION(S)] (paralysis on one side of the body) and [CONDITION(S)] (weakness on one side of the body) following cerebral infarction (ischemic stroke when disrupted blood flow to the brain due to problems with the blood vessels that supply it), idiopathic peripheral autonomic [CONDITION(S)] (damage of the peripheral nerves where cause cannot be determined), diabetes mellitus with diabetic [CONDITION(S)] (a type of nerve damage that can occur if you have diabetes), epileptic seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in your behavior. Having two or more seizures at least 24 hours apart that are not brought on by an identifiable cause is considered to be [CONDITION(S)]), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment), [CONDITION(S)] (a mental disorder characterized by a disconnection from reality), vascular dementia (brain damage caused by multiple strokes) with behavioral disturbances, cognitive communication deficit (difficulty with thinking and how someone uses language), and history of neoplasm of brain (abnormal masses of tissue that grow in the brain). Record review of Resident #1's MDS dated [DATE] revealed she sometimes understood others and responded adequately to simple, direct communication only; Resident #1 had a BIMS score of 3 (severe cognitive impairment); she had no indicators of [CONDITION(S)] and had no behaviors; she required extensive physical assistance from at least two staff for bed mobility (how resident moved to and from lying position, turned side to side, and positioned body while in bed or alternative sleep furniture), transfers, locomotion (via wheelchair), and toilet use; she required total assistance from staff for bathing; she required extensive physical assistance from at least one staff for dressing, eating, and personal hygiene; and she was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #1's care plan, updated on 06/24/2022 revealed she had an ADL self-care performance deficit due to [CONDITION(S)] and [CONDITION(S)] (has impairment to one side upper body and impairment to both sides of lower body) (Goal: The resident will maintain current level of function in ADL's. Interventions: Resident #1 requires extensive assistance with locomotion via wheelchair; Bed Mobility: the resident requires extensive assistance by 2 staff to turn and reposition in bed [Q2H] and as necessary; Dressing: The resident requires extensive assistance by 2 staff to dress; Eating: The resident requires extensive assistance by 1 staff to eat; Transfer: The resident requires extensive assistance by 2 staff to move between surfaces); Resident #1 had impaired cognitive function/dementia or impaired thought processes due to dementia (Goal: The resident will maintain current level of cognitive function. Interventions: Administer medications as ordered); she had an actual fall and received a laceration to right outer ankle on 05/10/2022 (Goal: The resident will resume usual activities without further incident. Interventions: Continue interventions on the at-risk plan; Monitor/document/report PRN to MD for s/sx of pain, change in mental status, confusion, sleepiness, inability to maintain posture, agitation); and she was at high risk for falls due to incontinence, psychoactive drug use, unaware of safety needs, and impaired mobility (Goal: The resident will not sustain serious injury. Interventions: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage resident to use it; Educate the resident/family/caregivers about safety reminders and what to do id a fall occurs: Follow facility fall protocol). Observation and interview with Resident #1 on 06/29/2022 at 2:00 p.m., revealed she was alert and oriented. Resident #1 was in bed with a fall mat at bedside. Most of Resident #1's fingers on both hands appeared to be deformed/contracted. Resident #1 said she really could not use her hands. Resident #1 stated she lived in the facility three years and fell recently when the bed rails were not up on the bed. She said the aide was changing her and rolled her over to the side. Resident #1 said she told the aide she was falling, but the aide acted like she was mad, and Resident #1 just fell on the floor. She said she did not have any injuries, but they took her to the hospital, and she stayed about one week (Resident #1 was cognitively impaired and confused the 05/10/2022 hospital visit with another unrelated hospital visit on 05/19/2022). Resident #1 said she fell towards the other side (she was laying on her left side) and the aide was standing on that side. Resident #1 said she fell towards the side where the aide was standing. She said she had a different bed when she fell . Resident #1 stated again that she fell when the side rails were not up. Record review of Resident #1's Fall Risk Evaluation dated 03/23/2022 revealed she was at risk with a score of 13. The document indicated Resident #1 had intermittent confusion; she had no falls in the previous 3 months, she was chair bound and required assistance with elimination; she had normal gait/balance, balance problems while standing, balance problems while walking, and decreased muscular coordination; and she had 1-2 predisposing diseases. Record review of Provider Investigation Report, signed by the Administrator dated on 05/17/2022 revealed on 05/10/2022 at 9:45 a.m., Resident #1 slid off her bed and sustained a small laceration to her right inner ankle when the bedrail gave away (broke). Resident #1 was assessed, given first aide, and sent out to a local ER for evaluation. Staff were educated on Accidents and Incidents, Managing Falls, ADL's assistance, and Abuse. Resident #1's bed was changed out to a new bed and her plan of care was updated. CNA A was listed as the alleged perpetrator (there was no documentation as to CNA A's role in the incident or why she was listed as an alleged perpetrator). The Investigation Summary read in part, 1). Facility followed its policies . 2). There was no identified neglect on part of facility; unfortunate equipment (bed) breakage. 3). Based on Interview, Record Review, and Observation throughout facility further abuse or neglect is unconfirmed/unfounded. 4). No conclusion of abuse or neglect could be substantiated. Record review of an undated, hand-written letter signed by CNA A revealed, The day 10th of May around 9:00 a.m. I entered Resident #1's room to check on her. She tells me she needs her diaper change. I get all my supplies and I begin to change her diaper. I turned Resident #1 to her right so I would be able to ger her sheets and diaper. When I tried to put the clean sheets back on all I hear is Resident #1 screamed to me to hold her out loud. When I noticed the siderail of her bed had broken down and all (I) was able to grab was her had. She rolled and took a pillow that end up laying on Resident #1 head in the floor. Record review of, Falls Investigation Worksheet, completed by ADON E and dated 05/10/2022 revealed on 05/10/2022, Resident #1 was found on the floor (right side) laying on her back. The document read in part, . What does the environment look like? . Bed Height: High . Record review of Resident #1's progress notes for May 2022 revealed: On 05/10/2022 at 10:00 a.m., ADON E wrote, Resident noted to be laying on the floor on her back, with head at next to the bedside dresser. Resident noted to have a laceration to right inner ankle (1.5 cm x 0 x 0.1). Resident states that when she was being turned to her right side, she slid off the bed. Nurse did a head-to-toe assessment on resident, vitals taken: 139/86, p 88, r 20, temperature 97.9. 911 called and informed of situation . On 05/10/2022 at 9:20 p.m., LVN D wrote, Resident arrived from hospital; transported by EMS, assisted x 2 attendants, stretcher used. Resident paperwork from hospital reads no fracture; resident on ABT x 10 days for abdominal wall [CONDITION(S)]. Resident right ankle/foot swollen, 2+ pitting [CONDITION(S)] (when excess fluid builds up in the body, causing swelling, when pressure is applied to the swollen area, a pit, or indentation will remain); right ankle/foot has ace bandage in place; resident moans in pain when turn or reposition, or moved . Record review of Resident #1's hospital medical records revealed she was seen at a local acute care hospitals ER and released on 05/10/2022. X-rays of Resident #1's ankle and bilateral hips and CT scans of her abdomen, brain, cervical spine, lumbar spine, and thoracic spine were negative. Resident #1 was diagnosed with accidental fall, acute back pain, and abdominal wall [CONDITION(S)]. In an interview with ADON E on 06/29/2022 at 11:50 a.m., he stated Resident #1 had a fall on 05/10/2022. He said CNA A repositioned her to the right side and while doing so, Resident #1 fell out of the bed onto the floor. ADON E said CNA A was providing Resident #1 with incontinent care. ADON E said CNA A told him she (CNA A) was putting Resident #1 on her side, and she did not know she pushed her that hard. ADON E said CNA A told him she (CNA A) did not know exactly what happened, but Resident #1 fell on the floor. ADON E said they (he did not specify who went to get him) came and got him and he noticed a laceration to her lower ankle. He said Resident #1 did not have a head injury, but she was sent out to the hospital for the laceration. ADON E said Resident #1 was bed bound and required a special wheelchair (Geri-chair) because of her contractures. In an interview with the Administrator on 06/29/2022 at 2:30 p.m., she stated when Resident #1 fell , the bedrail gave out. She said CNA A was changing Resident #1 and held on to the top part of her body when she started to fall. She said Resident #1's foot hit the foot board and bled, so the staff called 911. She said after the fall, they got Resident #1 floor mats and a new bed. She said they placed a sign over Resident #1's bed instructing staff to use two people when they provide incontinent care. She said Resident #1 was contracted but was alert and oriented. She said after Resident #1's bedrail gave out they threw the bed away. In an interview with CNA A on 11/07/2022 at 10:51 a.m., she stated she was hired by the facility in April 2022, and she always worked the 6:00 a.m. - 2:00 p.m. shift. She said Resident #1 had dementia and required feeding assistance, but she could assist with repositioning by holding on to the bedrails. She said Resident #1 had another bed when she fell on [DATE]. She said when Resident #1 fell , the quarter bedrail was up, but it was loose/broken, and it fell down when Resident #1 tried to grab it to hold on. She said Resident #1 would usually hold on to the rail, but they did not know the rail was broken until she fell . She said Resident #1's bed was changed out right after she fell . She said Resident #1 was currently a two-person assist for bed mobility, but she was a one-person assist for bed mobility when she fell . CNA A said she was on Resident #1's left side, and she turned Resident #1 to the right side, away from the side she was standing on. CNA A said it happened so fast. She said she heard the noise of the bedrail falling. She said Resident #1 screamed and was holding on to a pillow, so her head fell on the pillow on the floor. CNA A said Resident #1 was on the edge of the bed when she fell . She said she was holding Resident #1 with one hand and was putting the adult brief underneath her side. She said currently, they use two staff when providing Resident #1 incontinent care. In a follow-up interview with the Administrator on 11/07/2022 at 1:30 p.m., she said Resident #1 was a two-person assist for bed mobility when she fell on [DATE]. She said CNA A should have been aware of Resident #1's mobility status because CNAs had access to a certain section of their electronic resident records system which indicated how many staff should assist with ADL's. The Administrator stated Resident #1 only had that one fall since her admission and the fall was an accident due to faulty equipment. She said after Resident #1's fall, she audited each resident's MDS and placed a note with each resident's transfer/mobility status (including each resident's name, room number, bed location inside the room, transfer needs [number of staff necessary for transfer] and type of transfer) inside their closet doors. She stated Resident #1's hands were deformed as a person with [CONDITION(S)] (a progressive [CONDITION(S)] condition in which the immune system mistakenly attacks healthy cells and inflames joints, most commonly those found in the hands, wrists, and knees) and she could not even use them to feed herself. Observation of Resident #1's closet on 11/07/2022 at 1:40 p.m., revealed a typed document with her name, room number, bed location, and transfer status. Resident #1's document indicated she required maximum assistance with two staff. In an interview with Resident #1's family member on 11/07/2022 at 2:00 p.m., she stated she had to assist facility staff several times with incontinent care because the staff was alone. She said this happened even since the two-person assist sign was posted above Resident #1's bed. She said Resident #1 was officially diagnosed with [CONDITION(S)] since her admission to the facility but did have it when she still lived at home. She said Resident #1's hands and fingers were very curled up and disfigured when she fell in May 2022. She said Resident #1 was never capable of turning herself, assisting with bed mobility, or holding on to the bedrail. The family member said Resident #1's bedrail could not have been up when she fell . In an interview with the DON on 11/07/2022 at 2:30 p.m., he stated prior to Resident #1's fall on 05/10/2022, staff should have known how many staff were necessary for transfers and bed mobility by looking at the computer system. He said it was not likely that CNAs were looking at each resident's status in the computer system before assisting each resident each time, so they (administration) came up with putting each resident's status inside their closet doors. The DON said if there had been two staff present when Resident #1 fell on [DATE], it was possible she would not have fallen. He said Resident #1 was sent out to the hospital on 05/10/2022 because the amount of blood that came out of the small skin tear on her foot was alarming. He said Resident #1 lost a lot of blood, so the staff called 911. Record review of In-Service Training dated 05/10/2022 revealed the DON educated nursing staff on falls safety during incontinent care. The document read in part, . When the resident is not able to assist with repositioning during incontinent care there should be 2 people to prevent rolling out of bed. CNA's must know which residents require one/two people assist . Record review of facility policy, Fall and Fall Risk, Managing, revised December 2007 revealed, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation, Prioritizing Approaches to Managing Falls and Fall Risk. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions . Record review of undated facility policy, Fall Prevention Program revealed, Policy: The Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by and RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review fall risk assessments completed by the nursing department, as well as completing the Fall Resident Assessment Protocol, and if appropriate, a fall prevention protocol will be initiated. Purpose: To identify residents at risk in a timely manner. To gather accurate, objective, and consistent data for the purpose of implementing an individualized Plan of Care designed to meet the resident's needs. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls. To evaluate outcomes. Procedure: . 3. The results of the Fall Risk Assessment will be scored to identify the resident's risk category. Nursing personnel will begin implementation of the Fall Risk Intervention within 24 (hours). 4. All residents receiving a score of ten (10) or more will be considered at risk for falls .

Based on observation, interview, and record review, the facility failed to follow the plan of care for 4 of 6 residents (Resident #'s 21, 22, 23, and 24) reviewed for physician orders. --The facility failed to provide services in accordance with each residents written plan of care for 4 residents, #'s 21,22,23, and 24. An immediate jeopardy (IJ) was identified on 1/12/17. While the IJ was removed on 1/14/17, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy . The facility needed additional time to monitor and evaluate the effectiveness of their plan. This failure affected 4 residents and placed an 6 additional residents with a [DIAGNOSES REDACTED]. Findings included: Resident #21 Record Review of Resident #21's admission sheet revealed she was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #21's Speech Therapy/SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 5/19/15 revealed she was being treated for [REDACTED]. Record review of Resident #21's Significant Change MDS dated [DATE] revealed she was assessed as having severely impaired cognitive skills for daily decision making. She required the extensive assistance/limited assistance for eating. Nutritional revealed that malnutrition (protein or calorie) or at risk for malnutrition was checked. Her additional active [DIAGNOSES REDACTED]. Swallowing/Nutritional Status revealed she was assessed as having weight loss that was not due to a physician-prescribed weight loss regimen. She was assessed as having a weight loss of 5% or more in the last month or loss of 10 % or more in the last 6 months. She was on a mechanically altered diet-require change in texture of food or liquids. She had no natural teeth or had tooth fragment(s). Record review of Resident #21's plan of care dated 12/1/16 revealed care plans that included impaired cognition, visual deficit, impaired communication, ADL's,nutrition/weight loss, alteration in fluid balance, impaired skin integrity, poor dental health, hospice, and diabetes mellitus. Record review of Resident #21's December 2016 Physician order [REDACTED].>Record review of Resident #21's Diet Order & Communication sheet dated 1/22/16 revealed a diet change: Diet order: pureed diet. Texture: pureed. Record review of Resident #21's Dietary Data Set and Progress Note dated 1/16/16 revealed that she was dependent on staff to eat. Record review of the Physician order [REDACTED]. -Resident #21 - Order date 1/22/16 Regular Pureed. Observation on 1/10/17 at 10:00 a.m. of the Dietary Manager as she prepared the pureed lunch meal revealed she blended green beans and then she blended turkey using a mixer. The cornbread dressing had been previously blended and the mashed potatoes were a smooth consistency. She did not blend a dessert. Two sheet cakes with pink frosting were observed on the counter. Observation on 1/10/17 at 12:32 p.m. of Resident #21 revealed she was seated at the assisted feeding table. She had a slice of cake that was not pureed and did not appear to be soft or wet. Resident #21 was not interviewable. During an interview on 1/10/17 at 12:40 p.m. the Dietary Manager said the cake with frosting being served that day to all of the residents, had been soaked in a pudding poured on top for the residents on a pureed diet. She said they had been serving the cake that way for years. Observation on 1/11/17 at 12:47 p.m. of Resident #21 revealed she was seated at the assisted feeding table. Her meal of Sloppy Joe was pureed, but the bun under the sloppy Joe was not pureed. Record review of the Meal Tickets for Resident #21 revealed in part: - 1/10/17 Lunch - NAS-Pureed, pureed bread, pureed pears. - 1/12/17 Lunch - NAS-Pureed, pureed bread, pureed chilled peaches. Observation on 1/12/17 at 12:12 p.m. of Resident #21 revealed she was seated at the assisted feeding table. Her meal of pureed Meatloaf was served on top of a slice of white bread that was not pureed or entirely covered or soaked with the meat sauce. The staff did not mix or soak the bread before feeding it to her. Resident #22: Record review of the admission sheet for Resident #22 revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Resident #22 - Order date 10/06/15 Pureed Diet. Record review of the Speech Therapy evaluation dated 11/30/15 for Resident #22 indicated; Diagnoses: [REDACTED]. Recommendations: Diet = Puree Consistencies. Record review of Resident #22's Quarterly Minimum Data Set assessment dated [DATE] revealed she was totally dependent on staff for one-person physical assist with eating. She had short and long term memory problems. She was rarely/never understood and sometimes understood others. She had a mechanically altered diet. Record review of the Status Report form dated 12/19/16 sent to the dietary department from nursing revealed: Resident #22 - Diet: Pureed Diet. Record review of the Meal Tickets for Resident #22 revealed in part: - 1/10/17 - Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Dinner roll/bread, chilled pears. - 1/11/17 - Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Bun. - 1/12/17 Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Dinner roll/bread, chilled peaches. - 1/12/17 Dinner - Regular - Special consistency, Double portions/Serve Pureed Diet, Dinner roll/Bread, Chocolate Cake with frosting. - 1/13/17 Breakfast, Regular - Pureed, Pureed Bread - #16 scoop. Observation on 1/10/17 at 12:30 p.m. of Resident #22 revealed she was seated in a Geri-chair at an assisted feeding table. She had a slice of cake that was not pureed and did not appear to be soft or wet. She was not interviewable. Observation on 1/11/17 at 12:45 p.m. of Resident #22 revealed she was seated in her Geri-chair at the assisted feeding table. Her meal of sloppy Joe meat mixture was served on top of a bun that was not pureed. During an interview on 1/12/17 at 9:12 a.m. the Speech Therapist said she had worked with Resident #22 from 9/2016 - 10/2016. She said Resident #22 had silent aspiration and was on a pureed diet. She said residents on a pureed diet should not receive anything that was not pureed. She said cake with icing, unless it was completely soaked, would not be considered pureed. Observation on 1/12/17 at 12:10 p.m. of Resident #22 revealed she was seated in her Geri-chair at an assisted feeding table. Her meatloaf was served on top of a slice of white bread that was not pureed or entirely covered with the sauce to soak it. The staff did not attempt to coat/soak the bread before feeding it to her. Interview and testing on 1/12/17 at 12:25 p.m. of a pureed meal test tray with the Dietary Manager revealed a slice of white bread was observed not thoroughly covered/soaked with meat loaf and/or sauce. The white bread revealed all of the crust had not been cut off. When tasted, the white bread did not immediately dissolve. The Dietary Manager said the white bread needed to be soaked manually with the sauce if it was not covered with the sauce on the plate when it was served. The Dietary Manager said the facility had been serving it that way for years. During an interview on 1/12/17 at 5:26 p.m. CNA BY said she was not sure why Resident #22 had a special diet. She was not aware of the need to mix or stir the non-pureed cakes or breads before feeding Resident #22. Resident #23: Record review of Resident #23's admission sheet revealed she was an [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #23's Admission Minimum Data Set assessment dated [DATE] revealed she sometimes understood others and was sometimes understood. She was independent and required only set up from staff for eating. She had a mechanically altered diet. Record review of the Physician order [REDACTED]. -Resident #23 - Order date 10/07/16 Pureed Diet with Nectar Thicken Liquid. Record review of the Status Report form dated 6/01/16 sent to the dietary department from nursing revealed: Resident #23 - Diet: Dysphagia - Pureed. Record review of the Meal Tickets for Resident #23 indicated: - 1/10/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pureed pears. - 1/11/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pudding. - 1/12/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pureed chilled peaches. - 1/12/17 Dinner - Pureed, nectar thicken, pureed bread, pureed chocolate cake with frosting. - 1/13/16 Breakfast - Pureed, nectar thicken, pureed bread. Record review of the Speech Therapy evaluation dated 1/05/17 - 03/05/17 for Resident #23 revealed; Diagnoses: [REDACTED]. Current referral/Reason for referral: Due to exacerbation of decreased oral/pharyngeal function, risk of aspiration, and dysphagia. Swallow Tests - Yes (MBSS conducted on 10/05/16). Aspiration noted with mechanical soft solids. Silent aspiration was visualized. Recommendations: Diet - Solids = Puree Consistencies. Observation on 1/10/17 at 12:30 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her slice of cake that was not pureed did not appear to be soft or wet. During an interview on 1/10/17 at 12:30 p.m. with Resident #23 she asked what was on her plate, because she could not identify it. She said she did not like her pureed diet. Observation on 1/12/17 at 12:05 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her meal of pureed meatloaf was served on top of a slice of bread that was not pureed. Observation on 1/12/2017 at 5:40 p.m. revealed Resident #23 was in bed and had her dinner tray in front of her comprising as follows: -Pureed chicken and dumpling -A piece of bread with pureed meat on top of it -Pureed green beans -Chocolate cake with syrup -like liquid on top of it and was not pureed Resident #23 took a bite of the bread and said she did not like it. Observation on 1/13/2017 at 8:02 a.m. revealed Resident #23 was in bed and had her breakfast tray in front of her comprising as follows: -Pureed scrambled egg -A piece of bread with pureed sausage on top of it with some gravy but was not pureed -Pureed oatmeal She did not eat the bread. During an interview on 1/13/17 at 8:02 a.m. Resident #23 said that they were giving her a piece of bread with meat on top of it but she did not like it. During an interview with CNA AG on 1/13/2017 at 8:05 a.m. when asked what Resident #23 was served she said that it was a piece of bread. Asked if it was pureed she said no it was not pureed. During an interview with CNA BC on 1/13/2017 at 8:12 a.m. who was serving breakfast with 2 other CNAs. She said that usually two CNA s served breakfast on the halls but that three of them were serving that morning. She said that they normally checked the tray to make sure the ticket matched the food served for instance if the ticket said pureed, they would ensure that pureed diet was served. When asked what Resident #23 was served, she said that resident was served a piece of bread with gravy on top which softened the bread. Resident #24 Record Review of Resident #24's admission sheet revealed he was an [AGE] year old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Resident #24 - Order date 03/01/16 Large Portion Pureed. Record review of Resident #24's Quarterly Minimum Data Set assessment dated [DATE] revealed he was independent and required only set up from staff for eating. He had a mechanically altered diet. Record review of the Comprehensive Care Plans dated 6/26/16 for Resident #24 revealed he required supervision/setup with meals, and he was at risk for alteration in nutrition due to pureed diet. His approaches included: Diet as ordered. Record review of the Meal Tickets for Resident #24 indicated: - 1/10/17 Lunch - Regular - Pureed, large portions all meals, pureed bread, pureed pears. - 1/12/17 Lunch - Regular - Pureed, large portions all meals, pureed bread, pureed peaches. - 1/12/17 Dinner - Regular - Pureed, large portions all meals, pureed bread, pureed chocolate cake with frosting. Record review of the Speech Therapy evaluation dated 11/30/15 - 1/28/16 for Resident #24 revealed; Diagnoses: [REDACTED]. Recommendations: Diet - Solids = Puree Consistencies. Record review of the Physician order [REDACTED]. 12/15/16 Speech Therapy to evaluate and treat. 5 times each week for 4 weeks for dysphagia to include therapeutic strategies to improve oral pharyngeal swallow with safe swallow strategies. Observation on 1/12/17 at 12:04 p.m. of Resident #24 revealed he was seated in in the dining room eating his lunch. His meal of meat loaf was pureed and served on a slice of bread that was not pureed. During an interview on 1/12/17 at 3:00 p.m. the Dietary Consultant said the facility served cake to residents with physician orders [REDACTED]. He said they served cake, bread, and pancakes using the Slurry method of pouring and covering a food with a thickener dissolved in liquid, in order to soften it. He said the facility had used this method on cakes and breads for the past 4-5 years. He said the edges of the bread were cut off and meat and/or sauce was used to soften the bread and made it easier to swallow. He said yesterday (1/11/17) they had served the residents pureed sloppy Joe meat poured over a bun. He said he had consulted with the Speech Therapist in the past. He was unsure if the Speech Therapist was aware of their use of this slurry method for residents that received pureed diets. He said the slurry method was an approved method for residents with pureed diets and dysphagia. He said the slurried texture gave as close to normal appearance, making the foods more palatable for residents with dysphagia. When asked if there was a chance of aspiration if bread and/or cake was not completely soaked/slurried was served to residents on pureed diets, he said I would doubt it; there was no risk of aspiration. He said he did not know cake and/or bread had been served without being completely soaked or covered. Record review of the Diet Guide Sheets for 1/10/17-01/13/17 revealed the following Pureed diets for breads and desserts: - 1/10/17 Lunch - Pureed bread, pureed chilled pears. Dinner - Pureed bread, pureed cherry cobbler. - 1/11/17 Lunch - Pureed bread, vanilla pudding. Dinner - Pureed bread, pureed fruit mix. - 1/12/17 Lunch - Pureed bread, pureed chilled peaches. Dinner-Pureed bread, pureed chocolate cake & frosting. - 1/13/17 Lunch - Pureed bread, pureed chocolate brownie. Record review of the facility's undated Recipe for Cake, cookie, Brownie revealed: 1. Prepare dessert per recipe without seeds or nuts. 2. To puree: add milk to dessert and process to a pudding consistency. 3. To soak the dessert with slurry: place dessert in a sauce dish and cover with milk or juice slurry. Let stand 30 minutes or until thoroughly saturated and soft .Make sure the slurry has soaked into the dessert to decrease the potential for choking. Record review of the Consistency Modified Diets dated 2011 (from the contracted dietary services) provided by the Dietary Consultant as the facility policy revealed in part: .foods may be mechanically altered to a form that residents are able to consume as part of a therapeutic diet prescription in response to .medical conditions that cause dysphagia. The goal of these interventions is to provide foods in a form that facilitates ease and safety in swallowing . 1. Pureed: .foods should have a pudding or mousse like consistency. Most foods will be pureed and/or strained to ensure a smooth cohesive quality without lumps . Food Group - Grains, breads. Allowed - Pureed breads, .and desserts . Pre-gelled slurried products that are gelled through the entire thickness of the product. 2. Dysphagia-Ground: .foods that are moist, soft textured, and easily formed into a bolus. Chewing ability is required for this diet. Meats are ground and served with gravy/sauce for moisture to create a cohesive product. Other food products are served in a pureed form . Food Group-Grains, breads. Allowed- Pureed breads, .and desserts . Pre-gelled slurried products that are gelled through the entire thickness of the product. Regular bread products may be allowed on individualized basis as determined by the speech therapist and noted in the physician ' s diet order. Record review of the Blenderized Pureed diet dated 2011 (from the contracted dietary services company) provided by the Dietary Consultant as the facility's policy and procedure revealed in part: .The purpose of the Blenderized pureed diet is to meet the needs of residents with swallowing disorders. The Blenderized pureed diet is the puree diet with added liquid to thin to a drinkable consistency . The speech therapist will work with the dietician to assess residents and monitor their tolerance to dietary consistencies. Record review of the Dysphagia Level 1 Diet dated 1/12/17 from www.consultant360.com provided by the Dietary Consultant revealed in part: .Who orders a dysphagia pureed diet? Normally a speech therapist will recommend a dysphagia pureed diet .What types of foods are allowed on this diet? All foods are totally pureed to a pudding-like consistency. Food textures dysphagia pureed diet: Foods allowed-Breads: Pureed bread mixes, Pre-gelled slurried breads . Desserts: Smooth pudding, custards, yogurt, pureed desserts, and soufflés. Record review of the facility's undated Puree Diet Production Policy (from the contracted dietary services company) provided as the facility policy revealed in part: .Methods of puree production/provision should be reviewed with the facility's speech pathologist . Method 2: (Main entrée pureed-desserts and breads slurried) All main entrée items are prepared and pureed according to recipes and portions designed on the diet extensions. Bread, cakes, soft desserts are slurried to provide adequate texture for those residents with swallowing disorders . Method 3: (All items pureed-bread served with meat) The entire item (usually meats) shall be prepared per recipe for the meal being produced. The appropriate number of servings needed must be prepared with the same number of slices of bread . Method 4: (All items prepared, pureed, and served separately) All pureed items are to be prepared by recipe . Record review of the Dysphagia Pureed Diet dated 1/13/17 provided by the Speech Therapist revealed in part: Foods should be pudding-like . contains no lumps. The facility Administrator and DON were notified on 1/12/17 at 3:37 p.m. that an Immediate Jeopardy situation had been identified. A Plan of Removal (POR) of the IJ was submitted 1/12/17 . After revisions, a plan was accepted on 1/13/17. During an interview on 1/12/17 at 3:38 p.m. the Administrator said she was aware of residents with pureed diets being served cake. She said she was told they put pudding on top of the cake. She said the bread served to the residents with pureed diets had the meat and liquid/gravy on top of it. She said they had served it that way for years and there had been no incidents with aspiration/choking in that time. Immediate Jeopardy: Plan of Removal, 1/13/17: .The following actions will be taken immediately to ensure compliance and safety of all residents and to ensure all residents with a physician ordered pureed diet is served pureed foods. IMMEDIATE ACTION: All residents with physician ordered pureed diets were identified by the Director of Nursing or designee on 1/12/17. A 100% audit of diet orders was completed for accuracy and to ensure the consistency served to the residents is correct by the Director of Nursing or designee on 1/12/17. Any inconsistencies from the audit were identified and a communication form was completed by the Director of Nursing or designee and corrected by dietary personnel by updating the tray card system to reflect the correct physician order [REDACTED]. The Director of Nursing or designee in-serviced the CNAs and Licensed Nurses to check correct diet by matching the residents' tray cards with the consistency on the tray being served on 1/12/17 and 1/13/17. A 4-part communication form will be utilized by the Speech Therapist, Nursing Department and the Dietary Department for all dietary communications. The nursing staff will monitor all residents with a physician ordered pureed diet for signs and/or symptoms of aspiration (cough, nasal drip, watering eyes) and notify physician if any resident exhibits any of these symptoms. The current method of pureeing items of food was discontinued and the new method will be instated on 1/13/17. The Health Care Services Group District Manager in-serviced the Dietary Manager on 1/12/17 on the correct procedure for performing taste tests on pureed foods. This in-service included how to detect food particles that can be pocketed in the mouth of the tester and to ensure pudding consistency. A pureed food checklist will be utilized for the taste tests and to ensure pudding consistency. TRAINING: The Registered Dietician and the Health Care Services Group District Manager began training all dietary staff on the correct puree procedure immediately on 1/12/17 and continuing until all current in-house dietary staff have been trained to be 100% in-serviced by no later than 1/13/17. The Health Care Services Group district Manager Trained the Dietary Manager on 1/12/17 on the correct procedure for testing pureed and pudding consistency food. The Director of Nursing or designee began training all CNAs and Licensed Nurses on the correct procedure immediately on 1/12/17 and continuing until all current in-house clinical staff have been trained to be 100% in-serviced by no later than 1/13/17. The Administrator will ensure that any staff member that has not been in-serviced will not be allowed to work until the training has occurred. Education presented to the dietary staff consists of the following specifics, and was completed on 1/13/17: *Foods are prepared according to the regular meal plan, taking into account any therapeutic needs. Commercial blenders or robot coupes are used for consistent texture and conservation of nutritional value and integrity of food. *Meats, starches, and vegetables are pureed to a smooth consistency without lumps or solid materials. *Pureed items have a scoopable consistency or can be molded using forms. * Gravies and sauces may be added for moistening as needed. *Bread, pancakes, waffles, French toast, crackers, and biscuits should be served according to Physicians' Orders or as designated by facility Speech Therapist. *If Regular diet calls for cornbread, biscuit, muffin, garlic bread, etc.: serve in puree form using #16 scoop. Suggest garnishing with jelly or honey. MONITORING To ensure all residents with a physician ordered pureed diet are receiving pureed food only, the Dietary Manager or designee is using a taste test to ensure each food item is prepared properly. This taste test will consist of checking for pocketing food particles and ensuring no food particles stick to the roof of the tester's mouth. This test will be performed on all pureed foods prepared. In addition, a licensed nurse is checking all trays for accuracy and correct consistency by comparing the tray cards with the food/diet being served, both in the dining room and for trays delivered to the units and served in residents' rooms. The following activities occurred to determine the plan of removal had been implemented: During an interview on 1/13/17 at 8:00 a.m. with CNA BP, as she was serving meal trays in the dining room, she said pureed foods had to be blended up. They had to be served soft enough for the resident to swallow. She said she would take the tray back to the kitchen if the meal texture did not match the tray ticket. During an interview on 1/13/17 at 8:02 a.m. with LVN BI she said pureed foods had to be blended. If cake was served, or any other desserts, they needed to be pureed. She said she had seen slices of bread served before, but now the bread the resident's with pureed diets received was pureed, not sliced bread. She said she would return a tray to the kitchen if it did not have the correct texture/consistency of mechanical or pureed. During an interview on 1/13/17 at 8:07 a.m. with CNA AG, as she was serving the meal trays on hall 100, she said she matched the meals to the meal tickets to make sure residents received the right texture. She was aware that meals were mechanical, chopped, or pureed-blended. She said she would not serve a pureed meal if all the foods were not pureed. During an interview on 1/13/17 at 8:09 a.m. with CNA AJ she said pureed foods had to all be blended. She would take the tray back to the kitchen if she had any question about the texture. During interviews on 1/13/16 at 8:15 a.m. the Regional Director of Food Services and District Manager of the Food Services contracted company were in the kitchen. They said they had advised the Dietary Consultant to review all of the resident meal tickets. They would be serving all pureed foods if the resident's physician order [REDACTED]. Observation on 1/13/17 at 8:20 a.m. of Resident #21 revealed she was sitting at the assisted feeding table. She had pureed bread with pureed sausage on top of it, pureed eggs, and pureed oatmeal. Further observation on 1/13/17 at 12:00 p.m. revealed Resident #21's lunch meal was all pureed foods. Observation of Resident #21 on 1/13/17 at 8:38 a.m. revealed staff were there to assist her with eating breakfast which was a pureed meat (sausage) on top of a slice of pureed bread. Observation on 1/13/17 at 8:30 a.m. of Resident #24 revealed he was seated in in the dining room eating his breakfast. He had pureed bread on his plate, along with the rest of his pureed meal. Further observation on 1/13/17 at 12:00 p.m. revealed Resident #24's meal was all pureed, including his bread and his dessert. On 1/13/17 at 5:25 p.m. his meal of chicken and dumplings was pureed. His chocolate cake was in a small bowl covered with a liquid. 1/14/17 at 8:13 a.m. Observation of Resident #21 being assisted by staff with breakfast which was a pureed biscuit covered in gravy and meat completely saturated. Interview with LVN BI at 8:18 a.m. on 1/14/17 revealed she had been in-serviced on pureed diets and that the biscuit served for breakfast was pureed. Interview at 8:30 a.m. on 1/14/17 with CNA AG revealed she had received in-services that included pureed diets, diabetic diets, and meal tickets. During an interview on 1/13/17 at 10:35 a.m. with LVN AO she said the facility had provided additional training on pureed foods and resident meal tickets. She said resident meal trays were checked for food consistency and texture, particularly pureed diets. She said all the meal trays were inspected for diets before they were served. She was aware of signs and symptoms of aspiration. During an interview on 1/13/17 at 10:45 a.m. Dietary Staff A said she had received training on therapeutic diets. She said all pureed foods and desserts would now be blended/pureed. She said the bread they served was pureed bread. During an interview on 1/13/17 at 11:00 a.m. the Dietary Manager said she had received additional training on 1/12/17 which included neglect. Additional training had been provided to all dietary staff regarding blended pureed diets, a new check list system for pureed foods and tasting the pureed foods once they were blended for the taste and proper texture. During an interview on 1/13/17 at 12:00 p.m. the Speech Therapist said that when a resident was evaluated and a recommendation of pureed was given, an order was written and a communication form was given to the dietary department. She said she did not specify on the communication form if a resident could have their bread or dessert slurried/covered. She said the form of serving a food item completely slurried/soaked would cause it to be pureed. She said she had not seen bread or cake that was served to residents with pureed diets, served in a form in which it was not soaked completely. Observation on 1/13/17 at 12:00 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her entire meal, including her bread and her dessert was pureed. Observation on 1/13/17 at 12:15 p.m. of Resident #22 revealed she was seated in her Geri-chair at an assisted feeding table. Her meal of fish, spinach, macaroni and cheese, bread and a chocolate brownie was all pureed. During an interview on 1/13/17 at 12:45 p.m. with CNA AM she said foods had to be blended if the resident was on a pureed diet. They had to match the meal ticket with the meal trays before they were served to the residents. During an interview on 1/13/17 at 5:30 p.m. with CNA BY she was able to differentiate different dietary textures as regular, mechanical and/or pureed. She said pureed diets were blended. Observation on 1/13/17 at 5:50 p.m. CNA CF was in the room of Resident #28 feeding her dinner while the resident was lying in her bed. The head of the bed was raised. Her pureed meal consisted of chicken and dumplings, and vegetables. She had a small bowl of chocolate cake with frosting that was covered with a clear thickened liquid. Before she served Resident #28 the cake she stirred it until it was the same consistency as the pureed foods. During an interview on 1/13/17 at 5:50 p.m. CNA CF said Resident #28 always re

Based on observation, interview and record review, the facility failed to ensure that its resources were used effectively. The facility failed to provide services to residents according to their physician orders [REDACTED].#'s 21, 22, 23, and 24) reviewed for Therapeutic Diets. - The Administrator failed to ensure dietary staff prepared and served meals in accordance with physician prescribed therapeutic diets. --The Administrator failed to monitor food and nutrition services. An immediate jeopardy (IJ) was identified on 1/12/17. While the IJ was removed on 1/14/17, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. This failure affected 4 residents and placed 6 additional residents with [DIAGNOSES REDACTED]. Findings included: Resident #21 Record Review of Resident #21's admission sheet revealed she was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #21's Speech Therapy/SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 5/19/15 revealed she was being treated for [REDACTED]. Record review of Resident #21's Significant Change MDS dated [DATE] revealed she was assessed as having severely impaired cognitive skills for daily decision making. She required the extensive assistance/limited assistance for eating. Nutritional revealed that malnutrition (protein or calorie) or at risk for malnutrition was checked. Her additional active [DIAGNOSES REDACTED]. Swallowing/Nutritional Status revealed she was assessed as having weight loss that was not due to a physician-prescribed weight loss regimen. She was assessed as having a weight loss of 5% or more in the last month or loss of 10 % or more in the last 6 months. She was on a mechanically altered diet-require change in texture of food or liquids. She had no natural teeth or had tooth fragment(s). Record review of Resident #21's plan of care dated 12/1/16 revealed care plans that included impaired cognition, visual deficit, impaired communication, ADL's,nutrition/weight loss, alteration in fluid balance, impaired skin integrity, poor dental health, hospice, and diabetes mellitus. Record review of Resident #21's December 2016 Physician order [REDACTED].>Record review of Resident #21's Diet Order & Communication sheet dated 1/22/16 revealed a diet change: Diet order: pureed diet. Texture: pureed. Record review of Resident #21's Dietary Data Set and Progress Note dated 1/16/16 revealed that she was dependent on staff to eat. Record review of the Physician order [REDACTED]. -Resident #21 - Order date 1/22/16 Regular Pureed. Observation on 1/10/17 at 10:00 a.m. of the Dietary Manager as she prepared the pureed lunch meal revealed she blended green beans and then she blended turkey using a mixer. The cornbread dressing had been previously blended and the mashed potatoes were a smooth consistency. She did not blend a dessert. Two sheet cakes with pink frosting were observed on the counter. Observation on 1/10/17 at 12:32 p.m. of Resident #21 revealed she was seated at the assisted feeding table. She had a slice of cake that was not pureed and did not appear to be soft or wet. Resident #21 was not interviewable. During an interview on 1/10/17 at 12:40 p.m. the Dietary Manager said the cake with frosting being served that day to all of the residents, had been soaked in a pudding poured on top for the residents on a pureed diet. She said they had been serving the cake that way for years. Observation on 1/11/17 at 12:47 p.m. of Resident #21 revealed she was seated at the assisted feeding table. Her meal of Sloppy Joe was pureed, but the bun under the sloppy Joe was not pureed. Record review of the Meal Tickets for Resident #21 revealed in part: - 1/10/17 Lunch - NAS-Pureed, pureed bread, pureed pears. - 1/12/17 Lunch - NAS-Pureed, pureed bread, pureed chilled peaches. Observation on 1/12/17 at 12:12 p.m. of Resident #21 revealed she was seated at the assisted feeding table. Her meal of pureed Meatloaf was served on top of a slice of white bread that was not pureed or entirely covered or soaked with the meat sauce. The staff did not mix or soak the bread before feeding it to her. Resident #22: Record review of the admission sheet for Resident #22 revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Resident #22 - Order date 10/06/15 Pureed Diet. Record review of the Speech Therapy evaluation dated 11/30/15 for Resident #22 indicated; Diagnoses: [REDACTED]. Recommendations: Diet = Puree Consistencies. Record review of Resident #22's Quarterly Minimum Data Set assessment dated [DATE] revealed she was totally dependent on staff for one-person physical assist with eating. She had short and long term memory problems. She was rarely/never understood and sometimes understood others. She had a mechanically altered diet. Record review of the Status Report form dated 12/19/16 sent to the dietary department from nursing revealed: Resident #22 - Diet: Pureed Diet. Record review of the Meal Tickets for Resident #22 revealed in part: - 1/10/17 - Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Dinner roll/bread, chilled pears. - 1/11/17 - Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Bun. - 1/12/17 Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Dinner roll/bread, chilled peaches. - 1/12/17 Dinner - Regular - Special consistency, Double portions/Serve Pureed Diet, Dinner roll/Bread, Chocolate Cake with frosting. - 1/13/17 Breakfast, Regular - Pureed, Pureed Bread - #16 scoop. Observation on 1/10/17 at 12:30 p.m. of Resident #22 revealed she was seated in a Geri-chair at an assisted feeding table. She had a slice of cake that was not pureed and did not appear to be soft or wet. She was not interviewable. Observation on 1/11/17 at 12:45 p.m. of Resident #22 revealed she was seated in her Geri-chair at the assisted feeding table. Her meal of sloppy Joe meat mixture was served on top of a bun that was not pureed. During an interview on 1/12/17 at 9:12 a.m. the Speech Therapist said she had worked with Resident #22 from 9/2016 - 10/2016. She said Resident #22 had silent aspiration and was on a pureed diet. She said residents on a pureed diet should not receive anything that was not pureed. She said cake with icing, unless it was completely soaked, would not be considered pureed. Observation on 1/12/17 at 12:10 p.m. of Resident #22 revealed she was seated in her Geri-chair at an assisted feeding table. Her meatloaf was served on top of a slice of white bread that was not pureed or entirely covered with the sauce to soak it. The staff did not attempt to coat/soak the bread before feeding it to her. Interview and testing on 1/12/17 at 12:25 p.m. of a pureed meal test tray with the Dietary Manager revealed a slice of white bread was observed not thoroughly covered/soaked with meat loaf and/or sauce. The white bread revealed all of the crust had not been cut off. When tasted, the white bread did not immediately dissolve. The Dietary Manager said the white bread needed to be soaked manually with the sauce if it was not covered with the sauce on the plate when it was served. The Dietary Manager said the facility had been serving it that way for years. During an interview on 1/12/17 at 5:26 p.m. CNA BY said she was not sure why Resident #22 had a special diet. She was not aware of the need to mix or stir the non-pureed cakes or breads before feeding Resident #22. Resident #23: Record review of Resident #23's admission sheet revealed she was an [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #23's Admission Minimum Data Set assessment dated [DATE] revealed she sometimes understood others and was sometimes understood. She was independent and required only set up from staff for eating. She had a mechanically altered diet. Record review of the Physician order [REDACTED]. -Resident #23 - Order date 10/07/16 Pureed Diet with Nectar Thicken Liquid. Record review of the Status Report form dated 6/01/16 sent to the dietary department from nursing revealed: Resident #23 - Diet: Dysphagia - Pureed. Record review of the Meal Tickets for Resident #23 indicated: - 1/10/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pureed pears. - 1/11/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pudding. - 1/12/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pureed chilled peaches. - 1/12/17 Dinner - Pureed, nectar thicken, pureed bread, pureed chocolate cake with frosting. - 1/13/16 Breakfast - Pureed, nectar thicken, pureed bread. Record review of the Speech Therapy evaluation dated 1/05/17 - 03/05/17 for Resident #23 revealed; Diagnoses: [REDACTED]. Current referral/Reason for referral: Due to exacerbation of decreased oral/pharyngeal function, risk of aspiration, and dysphagia. Swallow Tests - Yes (MBSS conducted on 10/05/16). Aspiration noted with mechanical soft solids. Silent aspiration was visualized. Recommendations: Diet - Solids = Puree Consistencies. Observation on 1/10/17 at 12:30 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her slice of cake that was not pureed did not appear to be soft or wet. During an interview on 1/10/17 at 12:30 p.m. with Resident #23 she asked what was on her plate, because she could not identify it. She said she did not like her pureed diet. Observation on 1/12/17 at 12:05 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her meal of pureed meatloaf was served on top of a slice of bread that was not pureed. Observation on 1/12/2017 at 5:40 p.m. revealed Resident #23 was in bed and had her dinner tray in front of her comprising as follows: -Pureed chicken and dumpling -A piece of bread with pureed meat on top of it -Pureed green beans -Chocolate cake with syrup -like liquid on top of it and was not pureed Resident #23 took a bite of the bread and said she did not like it. Observation on 1/13/2017 at 8:02 a.m. revealed Resident #23 was in bed and had her breakfast tray in front of her comprising as follows: -Pureed scrambled egg -A piece of bread with pureed sausage on top of it with some gravy but was not pureed -Pureed oatmeal She did not eat the bread. During an interview on 1/13/17 at 8:02 a.m. Resident #23 said that they were giving her a piece of bread with meat on top of it but she did not like it. During an interview with CNA AG on 1/13/2017 at 8:05 a.m. when asked what Resident #23 was served she said that it was a piece of bread. Asked if it was pureed she said no it was not pureed. During an interview with CNA BC on 1/13/2017 at 8:12 a.m. who was serving breakfast with 2 other CNAs. She said that usually two CNA s served breakfast on the halls but that three of them were serving that morning. She said that they normally checked the tray to make sure the ticket matched the food served for instance if the ticket said pureed, they would ensure that pureed diet was served. When asked what Resident #23 was served, she said that resident was served a piece of bread with gravy on top which softened the bread. Resident #24 Record Review of Resident #24's admission sheet revealed he was an [AGE] year old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Resident #24 - Order date 03/01/16 Large Portion Pureed. Record review of Resident #24's Quarterly Minimum Data Set assessment dated [DATE] revealed he was independent and required only set up from staff for eating. He had a mechanically altered diet. Record review of the Comprehensive Care Plans dated 6/26/16 for Resident #24 revealed he required supervision/setup with meals, and he was at risk for alteration in nutrition due to pureed diet. His approaches included: Diet as ordered. Record review of the Meal Tickets for Resident #24 indicated: - 1/10/17 Lunch - Regular - Pureed, large portions all meals, pureed bread, pureed pears. - 1/12/17 Lunch - Regular - Pureed, large portions all meals, pureed bread, pureed peaches. - 1/12/17 Dinner - Regular - Pureed, large portions all meals, pureed bread, pureed chocolate cake with frosting. Record review of the Speech Therapy evaluation dated 11/30/15 - 1/28/16 for Resident #24 revealed; Diagnoses: [REDACTED]. Recommendations: Diet - Solids = Puree Consistencies. Record review of the Physician order [REDACTED]. 12/15/16 Speech Therapy to evaluate and treat. 5 times each week for 4 weeks for dysphagia to include therapeutic strategies to improve oral pharyngeal swallow with safe swallow strategies. Observation on 1/12/17 at 12:04 p.m. of Resident #24 revealed he was seated in in the dining room eating his lunch. His meal of meat loaf was pureed and served on a slice of bread that was not pureed. During an interview on 1/12/17 at 3:00 p.m. the Dietary Consultant said the facility served cake to residents with physician orders [REDACTED]. He said they served cake, bread, and pancakes using the Slurry method of pouring and covering a food with a thickener dissolved in liquid, in order to soften it. He said the facility had used this method on cakes and breads for the past 4-5 years. He said the edges of the bread were cut off and meat and/or sauce was used to soften the bread and made it easier to swallow. He said yesterday (1/11/17) they had served the residents pureed sloppy Joe meat poured over a bun. He said he had consulted with the Speech Therapist in the past. He was unsure if the Speech Therapist was aware of their use of this slurry method for residents that received pureed diets. He said the slurry method was an approved method for residents with pureed diets and dysphagia. He said the slurried texture gave as close to normal appearance, making the foods more palatable for residents with dysphagia. When asked if there was a chance of aspiration if bread and/or cake was not completely soaked/slurried was served to residents on pureed diets, he said I would doubt it; there was no risk of aspiration. He said he did not know cake and/or bread had been served without being completely soaked or covered. Record review of the Diet Guide Sheets for 1/10/17-01/13/17 revealed the following Pureed diets for breads and desserts: - 1/10/17 Lunch - Pureed bread, pureed chilled pears. Dinner - Pureed bread, pureed cherry cobbler. - 1/11/17 Lunch - Pureed bread, vanilla pudding. Dinner - Pureed bread, pureed fruit mix. - 1/12/17 Lunch - Pureed bread, pureed chilled peaches. Dinner-Pureed bread, pureed chocolate cake & frosting. - 1/13/17 Lunch - Pureed bread, pureed chocolate brownie. Record review of the facility's undated Recipe for Cake, cookie, Brownie revealed: 1. Prepare dessert per recipe without seeds or nuts. 2. To puree: add milk to dessert and process to a pudding consistency. 3. To soak the dessert with slurry: place dessert in a sauce dish and cover with milk or juice slurry. Let stand 30 minutes or until thoroughly saturated and soft .Make sure the slurry has soaked into the dessert to decrease the potential for choking. Record review of the Consistency Modified Diets dated 2011 (from the contracted dietary services) provided by the Dietary Consultant as the facility policy revealed in part: .foods may be mechanically altered to a form that residents are able to consume as part of a therapeutic diet prescription in response to .medical conditions that cause dysphagia. The goal of these interventions is to provide foods in a form that facilitates ease and safety in swallowing . 1. Pureed: .foods should have a pudding or mousse like consistency. Most foods will be pureed and/or strained to ensure a smooth cohesive quality without lumps . Food Group - Grains, breads. Allowed - Pureed breads, .and desserts . Pre-gelled slurried products that are gelled through the entire thickness of the product. 2. Dysphagia-Ground: .foods that are moist, soft textured, and easily formed into a bolus. Chewing ability is required for this diet. Meats are ground and served with gravy/sauce for moisture to create a cohesive product. Other food products are served in a pureed form . Food Group-Grains, breads. Allowed- Pureed breads, .and desserts . Pre-gelled slurried products that are gelled through the entire thickness of the product. Regular bread products may be allowed on individualized basis as determined by the speech therapist and noted in the physician ' s diet order. Record review of the Blenderized Pureed diet dated 2011 (from the contracted dietary services company) provided by the Dietary Consultant as the facility's policy and procedure revealed in part: .The purpose of the Blenderized pureed diet is to meet the needs of residents with swallowing disorders. The Blenderized pureed diet is the puree diet with added liquid to thin to a drinkable consistency . The speech therapist will work with the dietician to assess residents and monitor their tolerance to dietary consistencies. Record review of the Dysphagia Level 1 Diet dated 1/12/17 from www.consultant360.com provided by the Dietary Consultant revealed in part: .Who orders a dysphagia pureed diet? Normally a speech therapist will recommend a dysphagia pureed diet .What types of foods are allowed on this diet? All foods are totally pureed to a pudding-like consistency. Food textures dysphagia pureed diet: Foods allowed-Breads: Pureed bread mixes, Pre-gelled slurried breads . Desserts: Smooth pudding, custards, yogurt, pureed desserts, and soufflés. Record review of the facility's undated Puree Diet Production Policy (from the contracted dietary services company) provided as the facility policy revealed in part: .Methods of puree production/provision should be reviewed with the facility's speech pathologist . Method 2: (Main entrée pureed-desserts and breads slurried) All main entrée items are prepared and pureed according to recipes and portions designed on the diet extensions. Bread, cakes, soft desserts are slurried to provide adequate texture for those residents with swallowing disorders . Method 3: (All items pureed-bread served with meat) The entire item (usually meats) shall be prepared per recipe for the meal being produced. The appropriate number of servings needed must be prepared with the same number of slices of bread . Method 4: (All items prepared, pureed, and served separately) All pureed items are to be prepared by recipe . Record review of the Dysphagia Pureed Diet dated 1/13/17 provided by the Speech Therapist revealed in part: Foods should be pudding-like . contains no lumps. The facility Administrator and DON were notified on 1/12/17 at 3:37 p.m. that an Immediate Jeopardy situation had been identified. A Plan of Removal (POR) of the IJ was submitted 1/12/17 . After revisions, a plan was accepted on 1/13/17. During an interview on 1/12/17 at 3:38 p.m. the Administrator said she was aware of residents with pureed diets being served cake. She said she was told they put pudding on top of the cake. She said the bread served to the residents with pureed diets had the meat and liquid/gravy on top of it. She said they had served it that way for years and there had been no incidents with aspiration/choking in that time. Immediate Jeopardy: Plan of Removal, 1/13/17: .The following actions will be taken immediately to ensure compliance and safety of all residents and to ensure all residents with a physician ordered pureed diet is served pureed foods. IMMEDIATE ACTION: All residents with physician ordered pureed diets were identified by the Director of Nursing or designee on 1/12/17. A 100% audit of diet orders was completed for accuracy and to ensure the consistency served to the residents is correct by the Director of Nursing or designee on 1/12/17. Any inconsistencies from the audit were identified and a communication form was completed by the Director of Nursing or designee and corrected by dietary personnel by updating the tray card system to reflect the correct physician order [REDACTED]. The Director of Nursing or designee in-serviced the CNAs and Licensed Nurses to check correct diet by matching the residents' tray cards with the consistency on the tray being served on 1/12/17 and 1/13/17. A 4-part communication form will be utilized by the Speech Therapist, Nursing Department and the Dietary Department for all dietary communications. The nursing staff will monitor all residents with a physician ordered pureed diet for signs and/or symptoms of aspiration (cough, nasal drip, watering eyes) and notify physician if any resident exhibits any of these symptoms. The current method of pureeing items of food was discontinued and the new method will be instated on 1/13/17. The Health Care Services Group District Manager in-serviced the Dietary Manager on 1/12/17 on the correct procedure for performing taste tests on pureed foods. This in-service included how to detect food particles that can be pocketed in the mouth of the tester and to ensure pudding consistency. A pureed food checklist will be utilized for the taste tests and to ensure pudding consistency. TRAINING: The Registered Dietician and the Health Care Services Group District Manager began training all dietary staff on the correct puree procedure immediately on 1/12/17 and continuing until all current in-house dietary staff have been trained to be 100% in-serviced by no later than 1/13/17. The Health Care Services Group district Manager Trained the Dietary Manager on 1/12/17 on the correct procedure for testing pureed and pudding consistency food. The Director of Nursing or designee began training all CNAs and Licensed Nurses on the correct procedure immediately on 1/12/17 and continuing until all current in-house clinical staff have been trained to be 100% in-serviced by no later than 1/13/17. The Administrator will ensure that any staff member that has not been in-serviced will not be allowed to work until the training has occurred. Education presented to the dietary staff consists of the following specifics, and was completed on 1/13/17: *Foods are prepared according to the regular meal plan, taking into account any therapeutic needs. Commercial blenders or robot coupes are used for consistent texture and conservation of nutritional value and integrity of food. *Meats, starches, and vegetables are pureed to a smooth consistency without lumps or solid materials. *Pureed items have a scoopable consistency or can be molded using forms. * Gravies and sauces may be added for moistening as needed. *Bread, pancakes, waffles, French toast, crackers, and biscuits should be served according to Physicians' Orders or as designated by facility Speech Therapist. *If Regular diet calls for cornbread, biscuit, muffin, garlic bread, etc.: serve in puree form using #16 scoop. Suggest garnishing with jelly or honey. MONITORING To ensure all residents with a physician ordered pureed diet are receiving pureed food only, the Dietary Manager or designee is using a taste test to ensure each food item is prepared properly. This taste test will consist of checking for pocketing food particles and ensuring no food particles stick to the roof of the tester's mouth. This test will be performed on all pureed foods prepared. In addition, a licensed nurse is checking all trays for accuracy and correct consistency by comparing the tray cards with the food/diet being served, both in the dining room and for trays delivered to the units and served in residents' rooms. The following activities occurred to determine the plan of removal had been implemented: During an interview on 1/13/17 at 8:00 a.m. with CNA BP, as she was serving meal trays in the dining room, she said pureed foods had to be blended up. They had to be served soft enough for the resident to swallow. She said she would take the tray back to the kitchen if the meal texture did not match the tray ticket. During an interview on 1/13/17 at 8:02 a.m. with LVN BI she said pureed foods had to be blended. If cake was served, or any other desserts, they needed to be pureed. She said she had seen slices of bread served before, but now the bread the resident's with pureed diets received was pureed, not sliced bread. She said she would return a tray to the kitchen if it did not have the correct texture/consistency of mechanical or pureed. During an interview on 1/13/17 at 8:07 a.m. with CNA AG, as she was serving the meal trays on hall 100, she said she matched the meals to the meal tickets to make sure residents received the right texture. She was aware that meals were mechanical, chopped, or pureed-blended. She said she would not serve a pureed meal if all the foods were not pureed. During an interview on 1/13/17 at 8:09 a.m. with CNA AJ she said pureed foods had to all be blended. She would take the tray back to the kitchen if she had any question about the texture. During interviews on 1/13/16 at 8:15 a.m. the Regional Director of Food Services and District Manager of the Food Services contracted company were in the kitchen. They said they had advised the Dietary Consultant to review all of the resident meal tickets. They would be serving all pureed foods if the resident's physician order [REDACTED]. Observation on 1/13/17 at 8:20 a.m. of Resident #21 revealed she was sitting at the assisted feeding table. She had pureed bread with pureed sausage on top of it, pureed eggs, and pureed oatmeal. Further observation on 1/13/17 at 12:00 p.m. revealed Resident #21's lunch meal was all pureed foods. Observation of Resident #21 on 1/13/17 at 8:38 a.m. revealed staff were there to assist her with eating breakfast which was a pureed meat (sausage) on top of a slice of pureed bread. Observation on 1/13/17 at 8:30 a.m. of Resident #24 revealed he was seated in in the dining room eating his breakfast. He had pureed bread on his plate, along with the rest of his pureed meal. Further observation on 1/13/17 at 12:00 p.m. revealed Resident #24's meal was all pureed, including his bread and his dessert. On 1/13/17 at 5:25 p.m. his meal of chicken and dumplings was pureed. His chocolate cake was in a small bowl covered with a liquid. 1/14/17 at 8:13 a.m. Observation of Resident #21 being assisted by staff with breakfast which was a pureed biscuit covered in gravy and meat completely saturated. Interview with LVN BI at 8:18 a.m. on 1/14/17 revealed she had been in-serviced on pureed diets and that the biscuit served for breakfast was pureed. Interview at 8:30 a.m. on 1/14/17 with CNA AG revealed she had received in-services that included pureed diets, diabetic diets, and meal tickets. During an interview on 1/13/17 at 10:35 a.m. with LVN AO she said the facility had provided additional training on pureed foods and resident meal tickets. She said resident meal trays were checked for food consistency and texture, particularly pureed diets. She said all the meal trays were inspected for diets before they were served. She was aware of signs and symptoms of aspiration. During an interview on 1/13/17 at 10:45 a.m. Dietary Staff A said she had received training on therapeutic diets. She said all pureed foods and desserts would now be blended/pureed. She said the bread they served was pureed bread. During an interview on 1/13/17 at 11:00 a.m. the Dietary Manager said she had received additional training on 1/12/17 which included neglect. Additional training had been provided to all dietary staff regarding blended pureed diets, a new check list system for pureed foods and tasting the pureed foods once they were blended for the taste and proper texture. During an interview on 1/13/17 at 12:00 p.m. the Speech Therapist said that when a resident was evaluated and a recommendation of pureed was given, an order was written and a communication form was given to the dietary department. She said she did not specify on the communication form if a resident could have their bread or dessert slurried/covered. She said the form of serving a food item completely slurried/soaked would cause it to be pureed. She said she had not seen bread or cake that was served to residents with pureed diets, served in a form in which it was not soaked completely. Observation on 1/13/17 at 12:00 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her entire meal, including her bread and her dessert was pureed. Observation on 1/13/17 at 12:15 p.m. of Resident #22 revealed she was seated in her Geri-chair at an assisted feeding table. Her meal of fish, spinach, macaroni and cheese, bread and a chocolate brownie was all pureed. During an interview on 1/13/17 at 12:45 p.m. with CNA AM she said foods had to be blended if the resident was on a pureed diet. They had to match the meal ticket with the meal trays before they were served to the residents. During an interview on 1/13/17 at 5:30 p.m. with CNA BY she was able to differentiate different dietary textures as regular, mechanical and/or pureed. She said pureed diets were blended. Observation on 1/13/17 at 5:50 p.m. CNA CF was in the room of Resident #28 feeding her dinner while the resident was lying in her bed. The head of the bed was raised. Her pureed meal consisted of chicken and dumplings, and vegetables. She had a small bowl of chocolate cake with frosting that was covered with a clear thickened liquid. Before she ser

Based on observation, interview, and record review, the facility failed to ensure residents were free of neglect for 4 of 6 residents (#'s 21, 22, 23, and 24) reviewed for neglect in that: -The facility failed to provide pureed diets to residents with dysphagia who had physician orders [REDACTED].#'s 21, 22, 23, and 24. An immediate jeopardy (IJ) was identified on 1/12/17. While the IJ was removed on 1/14/17, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. This failure affected 4 residents and placed 6 additional residents with [DIAGNOSES REDACTED]. Findings included: Record review of the Abuse Prohibition Standards of Practice Policy dated as revised on 09/2016 indicated in part: The resident has the right to be free from mistreatment, neglect and misappropriation .residents will not be subject to any abuse by anyone, including, but not limited to, facility staff, .consultants, contractors .or staff of other agencies serving the resident .Definitions: .Neglect - The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #21 Record Review of Resident #21's admission sheet revealed she was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #21's Speech Therapy/SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 5/19/15 revealed she was being treated for [REDACTED]. Record review of Resident #21's Significant Change MDS dated [DATE] revealed she was assessed as having severely impaired cognitive skills for daily decision making. She required the extensive assistance/limited assistance for eating. Nutritional revealed that malnutrition (protein or calorie) or at risk for malnutrition was checked. Her additional active [DIAGNOSES REDACTED]. Swallowing/Nutritional Status revealed she was assessed as having weight loss that was not due to a physician-prescribed weight loss regimen. She was assessed as having a weight loss of 5% or more in the last month or loss of 10 % or more in the last 6 months. She was on a mechanically altered diet-require change in texture of food or liquids. She had no natural teeth or had tooth fragment(s). Record review of Resident #21's plan of care dated 12/1/16 revealed care plans that included impaired cognition, visual deficit, impaired communication, ADL's,nutrition/weight loss, alteration in fluid balance, impaired skin integrity, poor dental health, hospice, and diabetes mellitus. Record review of Resident #21's December 2016 Physician order [REDACTED].>Record review of Resident #21's Diet Order & Communication sheet dated 1/22/16 revealed a diet change: Diet order: pureed diet. Texture: pureed. Record review of Resident #21's Dietary Data Set and Progress Note dated 1/16/16 revealed that she was dependent on staff to eat. Record review of the Physician order [REDACTED]. -Resident #21 - Order date 1/22/16 Regular Pureed. Observation on 1/10/17 at 10:00 a.m. of the Dietary Manager as she prepared the pureed lunch meal revealed she blended green beans and then she blended turkey using a mixer. The cornbread dressing had been previously blended and the mashed potatoes were a smooth consistency. She did not blend a dessert. Two sheet cakes with pink frosting were observed on the counter. Observation on 1/10/17 at 12:32 p.m. of Resident #21 revealed she was seated at the assisted feeding table. She had a slice of cake that was not pureed and did not appear to be soft or wet. Resident #21 was not interviewable. During an interview on 1/10/17 at 12:40 p.m. the Dietary Manager said the cake with frosting being served that day to all of the residents, had been soaked in a pudding poured on top for the residents on a pureed diet. She said they had been serving the cake that way for years. Observation on 1/11/17 at 12:47 p.m. of Resident #21 revealed she was seated at the assisted feeding table. Her meal of Sloppy Joe was pureed, but the bun under the sloppy Joe was not pureed. Record review of the Meal Tickets for Resident #21 revealed in part: - 1/10/17 Lunch - NAS-Pureed, pureed bread, pureed pears. - 1/12/17 Lunch - NAS-Pureed, pureed bread, pureed chilled peaches. Observation on 1/12/17 at 12:12 p.m. of Resident #21 revealed she was seated at the assisted feeding table. Her meal of pureed Meatloaf was served on top of a slice of white bread that was not pureed or entirely covered or soaked with the meat sauce. The staff did not mix or soak the bread before feeding it to her. Resident #22: Record review of the admission sheet for Resident #22 revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Resident #22 - Order date 10/06/15 Pureed Diet. Record review of the Speech Therapy evaluation dated 11/30/15 for Resident #22 indicated; Diagnoses: [REDACTED]. Recommendations: Diet = Puree Consistencies. Record review of Resident #22's Quarterly Minimum Data Set assessment dated [DATE] revealed she was totally dependent on staff for one-person physical assist with eating. She had short and long term memory problems. She was rarely/never understood and sometimes understood others. She had a mechanically altered diet. Record review of the Status Report form dated 12/19/16 sent to the dietary department from nursing revealed: Resident #22 - Diet: Pureed Diet. Record review of the Meal Tickets for Resident #22 revealed in part: - 1/10/17 - Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Dinner roll/bread, chilled pears. - 1/11/17 - Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Bun. - 1/12/17 Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Dinner roll/bread, chilled peaches. - 1/12/17 Dinner - Regular - Special consistency, Double portions/Serve Pureed Diet, Dinner roll/Bread, Chocolate Cake with frosting. - 1/13/17 Breakfast, Regular - Pureed, Pureed Bread - #16 scoop. Observation on 1/10/17 at 12:30 p.m. of Resident #22 revealed she was seated in a Geri-chair at an assisted feeding table. She had a slice of cake that was not pureed and did not appear to be soft or wet. She was not interviewable. Observation on 1/11/17 at 12:45 p.m. of Resident #22 revealed she was seated in her Geri-chair at the assisted feeding table. Her meal of sloppy Joe meat mixture was served on top of a bun that was not pureed. During an interview on 1/12/17 at 9:12 a.m. the Speech Therapist said she had worked with Resident #22 from 9/2016 - 10/2016. She said Resident #22 had silent aspiration and was on a pureed diet. She said residents on a pureed diet should not receive anything that was not pureed. She said cake with icing, unless it was completely soaked, would not be considered pureed. Observation on 1/12/17 at 12:10 p.m. of Resident #22 revealed she was seated in her Geri-chair at an assisted feeding table. Her meatloaf was served on top of a slice of white bread that was not pureed or entirely covered with the sauce to soak it. The staff did not attempt to coat/soak the bread before feeding it to her. Interview and testing on 1/12/17 at 12:25 p.m. of a pureed meal test tray with the Dietary Manager revealed a slice of white bread was observed not thoroughly covered/soaked with meat loaf and/or sauce. The white bread revealed all of the crust had not been cut off. When tasted, the white bread did not immediately dissolve. The Dietary Manager said the white bread needed to be soaked manually with the sauce if it was not covered with the sauce on the plate when it was served. The Dietary Manager said the facility had been serving it that way for years. During an interview on 1/12/17 at 5:26 p.m. CNA BY said she was not sure why Resident #22 had a special diet. She was not aware of the need to mix or stir the non-pureed cakes or breads before feeding Resident #22. Resident #23: Record review of Resident #23's admission sheet revealed she was an [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #23's Admission Minimum Data Set assessment dated [DATE] revealed she sometimes understood others and was sometimes understood. She was independent and required only set up from staff for eating. She had a mechanically altered diet. Record review of the Physician order [REDACTED]. -Resident #23 - Order date 10/07/16 Pureed Diet with Nectar Thicken Liquid. Record review of the Status Report form dated 6/01/16 sent to the dietary department from nursing revealed: Resident #23 - Diet: Dysphagia - Pureed. Record review of the Meal Tickets for Resident #23 indicated: - 1/10/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pureed pears. - 1/11/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pudding. - 1/12/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pureed chilled peaches. - 1/12/17 Dinner - Pureed, nectar thicken, pureed bread, pureed chocolate cake with frosting. - 1/13/16 Breakfast - Pureed, nectar thicken, pureed bread. Record review of the Speech Therapy evaluation dated 1/05/17 - 03/05/17 for Resident #23 revealed; Diagnoses: [REDACTED]. Current referral/Reason for referral: Due to exacerbation of decreased oral/pharyngeal function, risk of aspiration, and dysphagia. Swallow Tests - Yes (MBSS conducted on 10/05/16). Aspiration noted with mechanical soft solids. Silent aspiration was visualized. Recommendations: Diet - Solids = Puree Consistencies. Observation on 1/10/17 at 12:30 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her slice of cake that was not pureed did not appear to be soft or wet. During an interview on 1/10/17 at 12:30 p.m. with Resident #23 she asked what was on her plate, because she could not identify it. She said she did not like her pureed diet. Observation on 1/12/17 at 12:05 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her meal of pureed meatloaf was served on top of a slice of bread that was not pureed. Observation on 1/12/2017 at 5:40 p.m. revealed Resident #23 was in bed and had her dinner tray in front of her comprising as follows: -Pureed chicken and dumpling -A piece of bread with pureed meat on top of it -Pureed green beans -Chocolate cake with syrup -like liquid on top of it and was not pureed Resident #23 took a bite of the bread and said she did not like it. Observation on 1/13/2017 at 8:02 a.m. revealed Resident #23 was in bed and had her breakfast tray in front of her comprising as follows: -Pureed scrambled egg -A piece of bread with pureed sausage on top of it with some gravy but was not pureed -Pureed oatmeal She did not eat the bread. During an interview on 1/13/17 at 8:02 a.m. Resident #23 said that they were giving her a piece of bread with meat on top of it but she did not like it. During an interview with CNA AG on 1/13/2017 at 8:05 a.m. when asked what Resident #23 was served she said that it was a piece of bread. Asked if it was pureed she said no it was not pureed. During an interview with CNA BC on 1/13/2017 at 8:12 a.m. who was serving breakfast with 2 other CNAs. She said that usually two CNA s served breakfast on the halls but that three of them were serving that morning. She said that they normally checked the tray to make sure the ticket matched the food served for instance if the ticket said pureed, they would ensure that pureed diet was served. When asked what Resident #23 was served, she said that resident was served a piece of bread with gravy on top which softened the bread. Resident #24 Record Review of Resident #24's admission sheet revealed he was an [AGE] year old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Resident #24 - Order date 03/01/16 Large Portion Pureed. Record review of Resident #24's Quarterly Minimum Data Set assessment dated [DATE] revealed he was independent and required only set up from staff for eating. He had a mechanically altered diet. Record review of the Comprehensive Care Plans dated 6/26/16 for Resident #24 revealed he required supervision/setup with meals, and he was at risk for alteration in nutrition due to pureed diet. His approaches included: Diet as ordered. Record review of the Meal Tickets for Resident #24 indicated: - 1/10/17 Lunch - Regular - Pureed, large portions all meals, pureed bread, pureed pears. - 1/12/17 Lunch - Regular - Pureed, large portions all meals, pureed bread, pureed peaches. - 1/12/17 Dinner - Regular - Pureed, large portions all meals, pureed bread, pureed chocolate cake with frosting. Record review of the Speech Therapy evaluation dated 11/30/15 - 1/28/16 for Resident #24 revealed; Diagnoses: [REDACTED]. Recommendations: Diet - Solids = Puree Consistencies. Record review of the Physician order [REDACTED]. 12/15/16 Speech Therapy to evaluate and treat. 5 times each week for 4 weeks for dysphagia to include therapeutic strategies to improve oral pharyngeal swallow with safe swallow strategies. Observation on 1/12/17 at 12:04 p.m. of Resident #24 revealed he was seated in in the dining room eating his lunch. His meal of meat loaf was pureed and served on a slice of bread that was not pureed. During an interview on 1/12/17 at 3:00 p.m. the Dietary Consultant said the facility served cake to residents with physician orders [REDACTED]. He said they served cake, bread, and pancakes using the Slurry method of pouring and covering a food with a thickener dissolved in liquid, in order to soften it. He said the facility had used this method on cakes and breads for the past 4-5 years. He said the edges of the bread were cut off and meat and/or sauce was used to soften the bread and made it easier to swallow. He said yesterday (1/11/17) they had served the residents pureed sloppy Joe meat poured over a bun. He said he had consulted with the Speech Therapist in the past. He was unsure if the Speech Therapist was aware of their use of this slurry method for residents that received pureed diets. He said the slurry method was an approved method for residents with pureed diets and dysphagia. He said the slurried texture gave as close to normal appearance, making the foods more palatable for residents with dysphagia. When asked if there was a chance of aspiration if bread and/or cake was not completely soaked/slurried was served to residents on pureed diets, he said I would doubt it; there was no risk of aspiration. He said he did not know cake and/or bread had been served without being completely soaked or covered. Record review of the Diet Guide Sheets for 1/10/17-01/13/17 revealed the following Pureed diets for breads and desserts: - 1/10/17 Lunch - Pureed bread, pureed chilled pears. Dinner - Pureed bread, pureed cherry cobbler. - 1/11/17 Lunch - Pureed bread, vanilla pudding. Dinner - Pureed bread, pureed fruit mix. - 1/12/17 Lunch - Pureed bread, pureed chilled peaches. Dinner-Pureed bread, pureed chocolate cake & frosting. - 1/13/17 Lunch - Pureed bread, pureed chocolate brownie. Record review of the facility's undated Recipe for Cake, cookie, Brownie revealed: 1. Prepare dessert per recipe without seeds or nuts. 2. To puree: add milk to dessert and process to a pudding consistency. 3. To soak the dessert with slurry: place dessert in a sauce dish and cover with milk or juice slurry. Let stand 30 minutes or until thoroughly saturated and soft .Make sure the slurry has soaked into the dessert to decrease the potential for choking. Record review of the Consistency Modified Diets dated 2011 (from the contracted dietary services) provided by the Dietary Consultant as the facility policy revealed in part: .foods may be mechanically altered to a form that residents are able to consume as part of a therapeutic diet prescription in response to .medical conditions that cause dysphagia. The goal of these interventions is to provide foods in a form that facilitates ease and safety in swallowing . 1. Pureed: .foods should have a pudding or mousse like consistency. Most foods will be pureed and/or strained to ensure a smooth cohesive quality without lumps . Food Group - Grains, breads. Allowed - Pureed breads, .and desserts . Pre-gelled slurried products that are gelled through the entire thickness of the product. 2. Dysphagia-Ground: .foods that are moist, soft textured, and easily formed into a bolus. Chewing ability is required for this diet. Meats are ground and served with gravy/sauce for moisture to create a cohesive product. Other food products are served in a pureed form . Food Group-Grains, breads. Allowed- Pureed breads, .and desserts . Pre-gelled slurried products that are gelled through the entire thickness of the product. Regular bread products may be allowed on individualized basis as determined by the speech therapist and noted in the physician ' s diet order. Record review of the Blenderized Pureed diet dated 2011 (from the contracted dietary services company) provided by the Dietary Consultant as the facility's policy and procedure revealed in part: .The purpose of the Blenderized pureed diet is to meet the needs of residents with swallowing disorders. The Blenderized pureed diet is the puree diet with added liquid to thin to a drinkable consistency . The speech therapist will work with the dietician to assess residents and monitor their tolerance to dietary consistencies. Record review of the Dysphagia Level 1 Diet dated 1/12/17 from www.consultant360.com provided by the Dietary Consultant revealed in part: .Who orders a dysphagia pureed diet? Normally a speech therapist will recommend a dysphagia pureed diet .What types of foods are allowed on this diet? All foods are totally pureed to a pudding-like consistency. Food textures dysphagia pureed diet: Foods allowed-Breads: Pureed bread mixes, Pre-gelled slurried breads . Desserts: Smooth pudding, custards, yogurt, pureed desserts, and soufflés. Record review of the facility's undated Puree Diet Production Policy (from the contracted dietary services company) provided as the facility policy revealed in part: .Methods of puree production/provision should be reviewed with the facility's speech pathologist . Method 2: (Main entrée pureed-desserts and breads slurried) All main entrée items are prepared and pureed according to recipes and portions designed on the diet extensions. Bread, cakes, soft desserts are slurried to provide adequate texture for those residents with swallowing disorders . Method 3: (All items pureed-bread served with meat) The entire item (usually meats) shall be prepared per recipe for the meal being produced. The appropriate number of servings needed must be prepared with the same number of slices of bread . Method 4: (All items prepared, pureed, and served separately) All pureed items are to be prepared by recipe . Record review of the Dysphagia Pureed Diet dated 1/13/17 provided by the Speech Therapist revealed in part: Foods should be pudding-like . contains no lumps. The facility Administrator and DON were notified on 1/12/17 at 3:37 p.m. that an Immediate Jeopardy situation had been identified. A Plan of Removal (POR) of the IJ was submitted 1/12/17 . After revisions, a plan was accepted on 1/13/17. During an interview on 1/12/17 at 3:38 p.m. the Administrator said she was aware of residents with pureed diets being served cake. She said she was told they put pudding on top of the cake. She said the bread served to the residents with pureed diets had the meat and liquid/gravy on top of it. She said they had served it that way for years and there had been no incidents with aspiration/choking in that time. Immediate Jeopardy: Plan of Removal, 1/13/17: .The following actions will be taken immediately to ensure compliance and safety of all residents and to ensure all residents with a physician ordered pureed diet is served pureed foods. IMMEDIATE ACTION: All residents with physician ordered pureed diets were identified by the Director of Nursing or designee on 1/12/17. A 100% audit of diet orders was completed for accuracy and to ensure the consistency served to the residents is correct by the Director of Nursing or designee on 1/12/17. Any inconsistencies from the audit were identified and a communication form was completed by the Director of Nursing or designee and corrected by dietary personnel by updating the tray card system to reflect the correct physician order [REDACTED]. The Director of Nursing or designee in-serviced the CNAs and Licensed Nurses to check correct diet by matching the residents' tray cards with the consistency on the tray being served on 1/12/17 and 1/13/17. A 4-part communication form will be utilized by the Speech Therapist, Nursing Department and the Dietary Department for all dietary communications. The nursing staff will monitor all residents with a physician ordered pureed diet for signs and/or symptoms of aspiration (cough, nasal drip, watering eyes) and notify physician if any resident exhibits any of these symptoms. The current method of pureeing items of food was discontinued and the new method will be instated on 1/13/17. The Health Care Services Group District Manager in-serviced the Dietary Manager on 1/12/17 on the correct procedure for performing taste tests on pureed foods. This in-service included how to detect food particles that can be pocketed in the mouth of the tester and to ensure pudding consistency. A pureed food checklist will be utilized for the taste tests and to ensure pudding consistency. TRAINING: The Registered Dietician and the Health Care Services Group District Manager began training all dietary staff on the correct puree procedure immediately on 1/12/17 and continuing until all current in-house dietary staff have been trained to be 100% in-serviced by no later than 1/13/17. The Health Care Services Group district Manager Trained the Dietary Manager on 1/12/17 on the correct procedure for testing pureed and pudding consistency food. The Director of Nursing or designee began training all CNAs and Licensed Nurses on the correct procedure immediately on 1/12/17 and continuing until all current in-house clinical staff have been trained to be 100% in-serviced by no later than 1/13/17. The Administrator will ensure that any staff member that has not been in-serviced will not be allowed to work until the training has occurred. Education presented to the dietary staff consists of the following specifics, and was completed on 1/13/17: *Foods are prepared according to the regular meal plan, taking into account any therapeutic needs. Commercial blenders or robot coupes are used for consistent texture and conservation of nutritional value and integrity of food. *Meats, starches, and vegetables are pureed to a smooth consistency without lumps or solid materials. *Pureed items have a scoopable consistency or can be molded using forms. * Gravies and sauces may be added for moistening as needed. *Bread, pancakes, waffles, French toast, crackers, and biscuits should be served according to Physicians' Orders or as designated by facility Speech Therapist. *If Regular diet calls for cornbread, biscuit, muffin, garlic bread, etc.: serve in puree form using #16 scoop. Suggest garnishing with jelly or honey. MONITORING To ensure all residents with a physician ordered pureed diet are receiving pureed food only, the Dietary Manager or designee is using a taste test to ensure each food item is prepared properly. This taste test will consist of checking for pocketing food particles and ensuring no food particles stick to the roof of the tester's mouth. This test will be performed on all pureed foods prepared. In addition, a licensed nurse is checking all trays for accuracy and correct consistency by comparing the tray cards with the food/diet being served, both in the dining room and for trays delivered to the units and served in residents' rooms. The following activities occurred to determine the plan of removal had been implemented: During an interview on 1/13/17 at 8:00 a.m. with CNA BP, as she was serving meal trays in the dining room, she said pureed foods had to be blended up. They had to be served soft enough for the resident to swallow. She said she would take the tray back to the kitchen if the meal texture did not match the tray ticket. During an interview on 1/13/17 at 8:02 a.m. with LVN BI she said pureed foods had to be blended. If cake was served, or any other desserts, they needed to be pureed. She said she had seen slices of bread served before, but now the bread the resident's with pureed diets received was pureed, not sliced bread. She said she would return a tray to the kitchen if it did not have the correct texture/consistency of mechanical or pureed. During an interview on 1/13/17 at 8:07 a.m. with CNA AG, as she was serving the meal trays on hall 100, she said she matched the meals to the meal tickets to make sure residents received the right texture. She was aware that meals were mechanical, chopped, or pureed-blended. She said she would not serve a pureed meal if all the foods were not pureed. During an interview on 1/13/17 at 8:09 a.m. with CNA AJ she said pureed foods had to all be blended. She would take the tray back to the kitchen if she had any question about the texture. During interviews on 1/13/16 at 8:15 a.m. the Regional Director of Food Services and District Manager of the Food Services contracted company were in the kitchen. They said they had advised the Dietary Consultant to review all of the resident meal tickets. They would be serving all pureed foods if the resident's physician order [REDACTED]. Observation on 1/13/17 at 8:20 a.m. of Resident #21 revealed she was sitting at the assisted feeding table. She had pureed bread with pureed sausage on top of it, pureed eggs, and pureed oatmeal. Further observation on 1/13/17 at 12:00 p.m. revealed Resident #21's lunch meal was all pureed foods. Observation of Resident #21 on 1/13/17 at 8:38 a.m. revealed staff were there to assist her with eating breakfast which was a pureed meat (sausage) on top of a slice of pureed bread. Observation on 1/13/17 at 8:30 a.m. of Resident #24 revealed he was seated in in the dining room eating his breakfast. He had pureed bread on his plate, along with the rest of his pureed meal. Further observation on 1/13/17 at 12:00 p.m. revealed Resident #24's meal was all pureed, including his bread and his dessert. On 1/13/17 at 5:25 p.m. his meal of chicken and dumplings was pureed. His chocolate cake was in a small bowl covered with a liquid. 1/14/17 at 8:13 a.m. Observation of Resident #21 being assisted by staff with breakfast which was a pureed biscuit covered in gravy and meat completely saturated. Interview with LVN BI at 8:18 a.m. on 1/14/17 revealed she had been in-serviced on pureed diets and that the biscuit served for breakfast was pureed. Interview at 8:30 a.m. on 1/14/17 with CNA AG revealed she had received in-services that included pureed diets, diabetic diets, and meal tickets. During an interview on 1/13/17 at 10:35 a.m. with LVN AO she said the facility had provided additional training on pureed foods and resident meal tickets. She said resident meal trays were checked for food consistency and texture, particularly pureed diets. She said all the meal trays were inspected for diets before they were served. She was aware of signs and symptoms of aspiration. During an interview on 1/13/17 at 10:45 a.m. Dietary Staff A said she had received training on therapeutic diets. She said all pureed foods and desserts would now be blended/pureed. She said the bread they served was pureed bread. During an interview on 1/13/17 at 11:00 a.m. the Dietary Manager said she had received additional training on 1/12/17 which included neglect. Additional training had been provided to all dietary staff regarding blended pureed diets, a new check list system for pureed foods and tasting the pureed foods once they were blended for the taste and proper texture. During an interview on 1/13/17 at 12:00 p.m. the Speech Therapist said that when a resident was evaluated and a recommendation of pureed was given, an order was written and a communication form was given to the dietary department. She said she did not specify on the communication form if a resident could have their bread or dessert slurried/covered. She said the form of serving a food item completely slurried/soaked would cause it to be pureed. She said she had not seen bread or cake that was served to residents with pureed diets, served in a form in which it was not soaked completely. Observation on 1/13/17 at 12:00 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her entire meal, including her bread and her dessert was pureed. Observation on 1/13/17 at 12:15 p.m. of Resident #22 revealed she was seated in her Geri-chair at an assisted feeding table. Her meal of fish, spinach, macaroni and cheese, bread and a chocolate brownie was all pureed. During an interview on 1/13/17 at 12:45 p.m. with CNA AM she said foods had to be blended if the resident was on a pureed diet. They had to match the meal ticket with the meal trays before they were served to the residents. During an interview on 1/13/17 at 5:30 p.m. with CNA BY she was able to differentiate different dietary textures as regu

Based on observation, interview and record review, the facility failed to provide a therapeutic diet as prescribed by their attending physician for 4 of 6 residents (Resident #'s 21, 22, 23, and 24) reviewed for Therapeutic Diets. Residents #'s 21,22, 23, and 24 were served food that was not pureed as ordered by the physician. An immediate jeopardy (IJ) was identified on 1/12/17. While the IJ was removed on 1/14/17, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. This failure affected 4 residents and placed 6 additional residents with a [DIAGNOSES REDACTED]. Findings included: Resident #21 Record Review of Resident #21's admission sheet revealed she was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #21's Speech Therapy/SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 5/19/15 revealed she was being treated for [REDACTED]. Record review of Resident #21's Significant Change MDS dated [DATE] revealed she was assessed as having severely impaired cognitive skills for daily decision making. She required the extensive assistance/limited assistance for eating. Nutritional revealed that malnutrition (protein or calorie) or at risk for malnutrition was checked. Her additional active [DIAGNOSES REDACTED]. Swallowing/Nutritional Status revealed she was assessed as having weight loss that was not due to a physician-prescribed weight loss regimen. She was assessed as having a weight loss of 5% or more in the last month or loss of 10 % or more in the last 6 months. She was on a mechanically altered diet-require change in texture of food or liquids. She had no natural teeth or had tooth fragment(s). Record review of Resident #21's plan of care dated 12/1/16 revealed care plans that included impaired cognition, visual deficit, impaired communication, ADL's,nutrition/weight loss, alteration in fluid balance, impaired skin integrity, poor dental health, hospice, and diabetes mellitus. Record review of Resident #21's December 2016 Physician order [REDACTED]. Record review of Resident #21's Diet Order & Communication sheet dated 1/22/16 revealed a diet change: Diet order: pureed diet. Texture: pureed. Record review of Resident #21's Dietary Data Set and Progress Note dated 1/16/16 revealed that she was dependent on staff to eat. Record review of the Physician order [REDACTED]. -Resident #21 - Order date 1/22/16 Regular Pureed. Observation on 1/10/17 at 10:00 a.m. of the Dietary Manager as she prepared the pureed lunch meal revealed she blended green beans and then she blended turkey using a mixer. The cornbread dressing had been previously blended and the mashed potatoes were a smooth consistency. She did not blend a dessert. Two sheet cakes with pink frosting were observed on the counter. Observation on 1/10/17 at 12:32 p.m. of Resident #21 revealed she was seated at the assisted feeding table. She had a slice of cake that was not pureed and did not appear to be soft or wet. Resident #21 was not interviewable. During an interview on 1/10/17 at 12:40 p.m. the Dietary Manager said the cake with frosting being served that day to all of the residents, had been soaked in a pudding poured on top for the residents on a pureed diet. She said they had been serving the cake that way for years. Observation on 1/11/17 at 12:47 p.m. of Resident #21 revealed she was seated at the assisted feeding table. Her meal of Sloppy Joe was pureed, but the bun under the sloppy Joe was not pureed. Record review of the Meal Tickets for Resident #21 revealed in part: - 1/10/17 Lunch - NAS-Pureed, pureed bread, pureed pears. - 1/12/17 Lunch - NAS-Pureed, pureed bread, pureed chilled peaches. Observation on 1/12/17 at 12:12 p.m. of Resident #21 revealed she was seated at the assisted feeding table. Her meal of pureed Meatloaf was served on top of a slice of white bread that was not pureed or entirely covered or soaked with the meat sauce. The staff did not mix or soak the bread before feeding it to her. Resident #22: Record review of the admission sheet for Resident #22 revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Resident #22 - Order date 10/06/15 Pureed Diet. Record review of the Speech Therapy evaluation dated 11/30/15 for Resident #22 indicated; Diagnoses: [REDACTED]. Recommendations: Diet = Puree Consistencies. Record review of Resident #22's Quarterly Minimum Data Set assessment dated [DATE] revealed she was totally dependent on staff for one-person physical assist with eating. She had short and long term memory problems. She was rarely/never understood and sometimes understood others. She had a mechanically altered diet. Record review of the Status Report form dated 12/19/16 sent to the dietary department from nursing revealed: Resident #22 - Diet: Pureed Diet. Record review of the Meal Tickets for Resident #22 revealed in part: - 1/10/17 - Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Dinner roll/bread, chilled pears. - 1/11/17 - Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Bun. - 1/12/17 Lunch - Regular - Special consistency, double portions/Serve Pureed Diet, Dinner roll/bread, chilled peaches. - 1/12/17 Dinner - Regular - Special consistency, Double portions/Serve Pureed Diet, Dinner roll/Bread, Chocolate Cake with frosting. - 1/13/17 Breakfast, Regular - Pureed, Pureed Bread - #16 scoop. Observation on 1/10/17 at 12:30 p.m. of Resident #22 revealed she was seated in a Geri-chair at an assisted feeding table. She had a slice of cake that was not pureed and did not appear to be soft or wet. She was not interviewable. Observation on 1/11/17 at 12:45 p.m. of Resident #22 revealed she was seated in her Geri-chair at the assisted feeding table. Her meal of sloppy Joe meat mixture was served on top of a bun that was not pureed. During an interview on 1/12/17 at 9:12 a.m. the Speech Therapist said she had worked with Resident #22 from 9/2016 - 10/2016. She said Resident #22 had silent aspiration and was on a pureed diet. She said residents on a pureed diet should not receive anything that was not pureed. She said cake with icing, unless it was completely soaked, would not be considered pureed. Observation on 1/12/17 at 12:10 p.m. of Resident #22 revealed she was seated in her Geri-chair at an assisted feeding table. Her meatloaf was served on top of a slice of white bread that was not pureed or entirely covered with the sauce to soak it. The staff did not attempt to coat/soak the bread before feeding it to her. Interview and testing on 1/12/17 at 12:25 p.m. of a pureed meal test tray with the Dietary Manager revealed a slice of white bread was observed not thoroughly covered/soaked with meat loaf and/or sauce. The white bread revealed all of the crust had not been cut off. When tasted, the white bread did not immediately dissolve. The Dietary Manager said the white bread needed to be soaked manually with the sauce if it was not covered with the sauce on the plate when it was served. The Dietary Manager said the facility had been serving it that way for years. During an interview on 1/12/17 at 5:26 p.m. CNA BY said she was not sure why Resident #22 had a special diet. She was not aware of the need to mix or stir the non-pureed cakes or breads before feeding Resident #22. Resident #23: Record review of Resident #23's admission sheet revealed she was an [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #23's Admission Minimum Data Set assessment dated [DATE] revealed she sometimes understood others and was sometimes understood. She was independent and required only set up from staff for eating. She had a mechanically altered diet. Record review of the Physician order [REDACTED]. -Resident #23 - Order date 10/07/16 Pureed Diet with Nectar Thicken Liquid. Record review of the Status Report form dated 6/01/16 sent to the dietary department from nursing revealed: Resident #23 - Diet: Dysphagia - Pureed. Record review of the Meal Tickets for Resident #23 indicated: - 1/10/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pureed pears. - 1/11/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pudding. - 1/12/17 Lunch - Regular - Pureed, nectar thicken, pureed bread, pureed chilled peaches. - 1/12/17 Dinner - Pureed, nectar thicken, pureed bread, pureed chocolate cake with frosting. - 1/13/16 Breakfast - Pureed, nectar thicken, pureed bread. Record review of the Speech Therapy evaluation dated 1/05/17 - 03/05/17 for Resident #23 revealed; Diagnoses: [REDACTED]. Current referral/Reason for referral: Due to exacerbation of decreased oral/pharyngeal function, risk of aspiration, and dysphagia. Swallow Tests - Yes (MBSS conducted on 10/05/16). Aspiration noted with mechanical soft solids. Silent aspiration was visualized. Recommendations: Diet - Solids = Puree Consistencies. Observation on 1/10/17 at 12:30 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her slice of cake that was not pureed did not appear to be soft or wet. During an interview on 1/10/17 at 12:30 p.m. with Resident #23 she asked what was on her plate, because she could not identify it. She said she did not like her pureed diet. Observation on 1/12/17 at 12:05 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her meal of pureed meatloaf was served on top of a slice of bread that was not pureed. Observation on 1/12/2017 at 5:40 p.m. revealed Resident #23 was in bed and had her dinner tray in front of her comprising as follows: -Pureed chicken and dumpling -A piece of bread with pureed meat on top of it -Pureed green beans -Chocolate cake with syrup -like liquid on top of it and was not pureed Resident #23 took a bite of the bread and said she did not like it. Observation on 1/13/2017 at 8:02 a.m. revealed Resident #23 was in bed and had her breakfast tray in front of her comprising as follows: -Pureed scrambled egg -A piece of bread with pureed sausage on top of it with some gravy but was not pureed -Pureed oatmeal She did not eat the bread. During an interview on 1/13/17 at 8:02 a.m. Resident #23 said that they were giving her a piece of bread with meat on top of it but she did not like it. During an interview with CNA AG on 1/13/2017 at 8:05 a.m. when asked what Resident #23 was served she said that it was a piece of bread. Asked if it was pureed she said no it was not pureed. During an interview with CNA BC on 1/13/2017 at 8:12 a.m. who was serving breakfast with 2 other CNAs. She said that usually two CNA s served breakfast on the halls but that three of them were serving that morning. She said that they normally checked the tray to make sure the ticket matched the food served for instance if the ticket said pureed, they would ensure that pureed diet was served. When asked what Resident #23 was served, she said that resident was served a piece of bread with gravy on top which softened the bread. Resident #24 Record Review of Resident #24's admission sheet revealed he was an [AGE] year old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. -Resident #24 - Order date 03/01/16 Large Portion Pureed. Record review of Resident #24's Quarterly Minimum Data Set assessment dated [DATE] revealed he was independent and required only set up from staff for eating. He had a mechanically altered diet. Record review of the Comprehensive Care Plans dated 6/26/16 for Resident #24 revealed he required supervision/setup with meals, and he was at risk for alteration in nutrition due to pureed diet. His approaches included: Diet as ordered. Record review of the Meal Tickets for Resident #24 indicated: - 1/10/17 Lunch - Regular - Pureed, large portions all meals, pureed bread, pureed pears. - 1/12/17 Lunch - Regular - Pureed, large portions all meals, pureed bread, pureed peaches. - 1/12/17 Dinner - Regular - Pureed, large portions all meals, pureed bread, pureed chocolate cake with frosting. Record review of the Speech Therapy evaluation dated 11/30/15 - 1/28/16 for Resident #24 revealed; Diagnoses: [REDACTED]. Recommendations: Diet - Solids = Puree Consistencies. Record review of the Physician order [REDACTED]. 12/15/16 Speech Therapy to evaluate and treat. 5 times each week for 4 weeks for dysphagia to include therapeutic strategies to improve oral pharyngeal swallow with safe swallow strategies. Observation on 1/12/17 at 12:04 p.m. of Resident #24 revealed he was seated in in the dining room eating his lunch. His meal of meat loaf was pureed and served on a slice of bread that was not pureed. During an interview on 1/12/17 at 3:00 p.m. the Dietary Consultant said the facility served cake to residents with physician orders [REDACTED]. He said they served cake, bread, and pancakes using the Slurry method of pouring and covering a food with a thickener dissolved in liquid, in order to soften it. He said the facility had used this method on cakes and breads for the past 4-5 years. He said the edges of the bread were cut off and meat and/or sauce was used to soften the bread and made it easier to swallow. He said yesterday (1/11/17) they had served the residents pureed sloppy Joe meat poured over a bun. He said he had consulted with the Speech Therapist in the past. He was unsure if the Speech Therapist was aware of their use of this slurry method for residents that received pureed diets. He said the slurry method was an approved method for residents with pureed diets and dysphagia. He said the slurried texture gave as close to normal appearance, making the foods more palatable for residents with dysphagia. When asked if there was a chance of aspiration if bread and/or cake was not completely soaked/slurried was served to residents on pureed diets, he said I would doubt it; there was no risk of aspiration. He said he did not know cake and/or bread had been served without being completely soaked or covered. Record review of the Diet Guide Sheets for 1/10/17-01/13/17 revealed the following Pureed diets for breads and desserts: - 1/10/17 Lunch - Pureed bread, pureed chilled pears. Dinner - Pureed bread, pureed cherry cobbler. - 1/11/17 Lunch - Pureed bread, vanilla pudding. Dinner - Pureed bread, pureed fruit mix. - 1/12/17 Lunch - Pureed bread, pureed chilled peaches. Dinner-Pureed bread, pureed chocolate cake & frosting. - 1/13/17 Lunch - Pureed bread, pureed chocolate brownie. Record review of the facility's undated Recipe for Cake, cookie, Brownie revealed: 1. Prepare dessert per recipe without seeds or nuts. 2. To puree: add milk to dessert and process to a pudding consistency. 3. To soak the dessert with slurry: place dessert in a sauce dish and cover with milk or juice slurry. Let stand 30 minutes or until thoroughly saturated and soft .Make sure the slurry has soaked into the dessert to decrease the potential for choking. Record review of the Consistency Modified Diets dated 2011 (from the contracted dietary services) provided by the Dietary Consultant as the facility policy revealed in part: .foods may be mechanically altered to a form that residents are able to consume as part of a therapeutic diet prescription in response to .medical conditions that cause dysphagia. The goal of these interventions is to provide foods in a form that facilitates ease and safety in swallowing . 1. Pureed: .foods should have a pudding or mousse like consistency. Most foods will be pureed and/or strained to ensure a smooth cohesive quality without lumps . Food Group - Grains, breads. Allowed - Pureed breads, .and desserts . Pre-gelled slurried products that are gelled through the entire thickness of the product. 2. Dysphagia-Ground: .foods that are moist, soft textured, and easily formed into a bolus. Chewing ability is required for this diet. Meats are ground and served with gravy/sauce for moisture to create a cohesive product. Other food products are served in a pureed form . Food Group-Grains, breads. Allowed- Pureed breads, .and desserts . Pre-gelled slurried products that are gelled through the entire thickness of the product. Regular bread products may be allowed on individualized basis as determined by the speech therapist and noted in the physician ' s diet order. Record review of the Blenderized Pureed diet dated 2011 (from the contracted dietary services company) provided by the Dietary Consultant as the facility's policy and procedure revealed in part: .The purpose of the Blenderized pureed diet is to meet the needs of residents with swallowing disorders. The Blenderized pureed diet is the puree diet with added liquid to thin to a drinkable consistency . The speech therapist will work with the dietician to assess residents and monitor their tolerance to dietary consistencies. Record review of the Dysphagia Level 1 Diet dated 1/12/17 from www.consultant360.com provided by the Dietary Consultant revealed in part: .Who orders a dysphagia pureed diet? Normally a speech therapist will recommend a dysphagia pureed diet .What types of foods are allowed on this diet? All foods are totally pureed to a pudding-like consistency. Food textures dysphagia pureed diet: Foods allowed-Breads: Pureed bread mixes, Pre-gelled slurried breads . Desserts: Smooth pudding, custards, yogurt, pureed desserts, and soufflés. Record review of the facility's undated Puree Diet Production Policy (from the contracted dietary services company) provided as the facility policy revealed in part: .Methods of puree production/provision should be reviewed with the facility's speech pathologist . Method 2: (Main entrée pureed-desserts and breads slurried) All main entrée items are prepared and pureed according to recipes and portions designed on the diet extensions. Bread, cakes, soft desserts are slurried to provide adequate texture for those residents with swallowing disorders . Method 3: (All items pureed-bread served with meat) The entire item (usually meats) shall be prepared per recipe for the meal being produced. The appropriate number of servings needed must be prepared with the same number of slices of bread . Method 4: (All items prepared, pureed, and served separately) All pureed items are to be prepared by recipe . Record review of the Dysphagia Pureed Diet dated 1/13/17 provided by the Speech Therapist revealed in part: Foods should be pudding-like . contains no lumps. The facility Administrator and DON were notified on 1/12/17 at 3:37 p.m. that an Immediate Jeopardy situation had been identified. A Plan of Removal (POR) of the IJ was submitted 1/12/17 . After revisions, a plan was accepted on 1/13/17. During an interview on 1/12/17 at 3:38 p.m. the Administrator said she was aware of residents with pureed diets being served cake. She said she was told they put pudding on top of the cake. She said the bread served to the residents with pureed diets had the meat and liquid/gravy on top of it. She said they had served it that way for years and there had been no incidents with aspiration/choking in that time. Immediate Jeopardy: Plan of Removal, 1/13/17: .The following actions will be taken immediately to ensure compliance and safety of all residents and to ensure all residents with a physician ordered pureed diet is served pureed foods. IMMEDIATE ACTION: All residents with physician ordered pureed diets were identified by the Director of Nursing or designee on 1/12/17. A 100% audit of diet orders was completed for accuracy and to ensure the consistency served to the residents is correct by the Director of Nursing or designee on 1/12/17. Any inconsistencies from the audit were identified and a communication form was completed by the Director of Nursing or designee and corrected by dietary personnel by updating the tray card system to reflect the correct physician order [REDACTED]. The Director of Nursing or designee in-serviced the CNAs and Licensed Nurses to check correct diet by matching the residents' tray cards with the consistency on the tray being served on 1/12/17 and 1/13/17. A 4-part communication form will be utilized by the Speech Therapist, Nursing Department and the Dietary Department for all dietary communications. The nursing staff will monitor all residents with a physician ordered pureed diet for signs and/or symptoms of aspiration (cough, nasal drip, watering eyes) and notify physician if any resident exhibits any of these symptoms. The current method of pureeing items of food was discontinued and the new method will be instated on 1/13/17. The Health Care Services Group District Manager in-serviced the Dietary Manager on 1/12/17 on the correct procedure for performing taste tests on pureed foods. This in-service included how to detect food particles that can be pocketed in the mouth of the tester and to ensure pudding consistency. A pureed food checklist will be utilized for the taste tests and to ensure pudding consistency. TRAINING: The Registered Dietician and the Health Care Services Group District Manager began training all dietary staff on the correct puree procedure immediately on 1/12/17 and continuing until all current in-house dietary staff have been trained to be 100% in-serviced by no later than 1/13/17. The Health Care Services Group district Manager Trained the Dietary Manager on 1/12/17 on the correct procedure for testing pureed and pudding consistency food. The Director of Nursing or designee began training all CNAs and Licensed Nurses on the correct procedure immediately on 1/12/17 and continuing until all current in-house clinical staff have been trained to be 100% in-serviced by no later than 1/13/17. The Administrator will ensure that any staff member that has not been in-serviced will not be allowed to work until the training has occurred. Education presented to the dietary staff consists of the following specifics, and was completed on 1/13/17: *Foods are prepared according to the regular meal plan, taking into account any therapeutic needs. Commercial blenders or robot coupes are used for consistent texture and conservation of nutritional value and integrity of food. *Meats, starches, and vegetables are pureed to a smooth consistency without lumps or solid materials. *Pureed items have a scoopable consistency or can be molded using forms. * Gravies and sauces may be added for moistening as needed. *Bread, pancakes, waffles, French toast, crackers, and biscuits should be served according to Physicians' Orders or as designated by facility Speech Therapist. *If Regular diet calls for cornbread, biscuit, muffin, garlic bread, etc.: serve in puree form using #16 scoop. Suggest garnishing with jelly or honey. MONITORING To ensure all residents with a physician ordered pureed diet are receiving pureed food only, the Dietary Manager or designee is using a taste test to ensure each food item is prepared properly. This taste test will consist of checking for pocketing food particles and ensuring no food particles stick to the roof of the tester's mouth. This test will be performed on all pureed foods prepared. In addition, a licensed nurse is checking all trays for accuracy and correct consistency by comparing the tray cards with the food/diet being served, both in the dining room and for trays delivered to the units and served in residents' rooms. The following activities occurred to determine the plan of removal had been implemented: During an interview on 1/13/17 at 8:00 a.m. with CNA BP, as she was serving meal trays in the dining room, she said pureed foods had to be blended up. They had to be served soft enough for the resident to swallow. She said she would take the tray back to the kitchen if the meal texture did not match the tray ticket. During an interview on 1/13/17 at 8:02 a.m. with LVN BI she said pureed foods had to be blended. If cake was served, or any other desserts, they needed to be pureed. She said she had seen slices of bread served before, but now the bread the resident's with pureed diets received was pureed, not sliced bread. She said she would return a tray to the kitchen if it did not have the correct texture/consistency of mechanical or pureed. During an interview on 1/13/17 at 8:07 a.m. with CNA AG, as she was serving the meal trays on hall 100, she said she matched the meals to the meal tickets to make sure residents received the right texture. She was aware that meals were mechanical, chopped, or pureed-blended. She said she would not serve a pureed meal if all the foods were not pureed. During an interview on 1/13/17 at 8:09 a.m. with CNA AJ she said pureed foods had to all be blended. She would take the tray back to the kitchen if she had any question about the texture. During interviews on 1/13/16 at 8:15 a.m. the Regional Director of Food Services and District Manager of the Food Services contracted company were in the kitchen. They said they had advised the Dietary Consultant to review all of the resident meal tickets. They would be serving all pureed foods if the resident's physician order [REDACTED]. Observation on 1/13/17 at 8:20 a.m. of Resident #21 revealed she was sitting at the assisted feeding table. She had pureed bread with pureed sausage on top of it, pureed eggs, and pureed oatmeal. Further observation on 1/13/17 at 12:00 p.m. revealed Resident #21's lunch meal was all pureed foods. Observation of Resident #21 on 1/13/17 at 8:38 a.m. revealed staff were there to assist her with eating breakfast which was a pureed meat (sausage) on top of a slice of pureed bread. Observation on 1/13/17 at 8:30 a.m. of Resident #24 revealed he was seated in in the dining room eating his breakfast. He had pureed bread on his plate, along with the rest of his pureed meal. Further observation on 1/13/17 at 12:00 p.m. revealed Resident #24's meal was all pureed, including his bread and his dessert. On 1/13/17 at 5:25 p.m. his meal of chicken and dumplings was pureed. His chocolate cake was in a small bowl covered with a liquid. 1/14/17 at 8:13 a.m. Observation of Resident #21 being assisted by staff with breakfast which was a pureed biscuit covered in gravy and meat completely saturated. Interview with LVN BI at 8:18 a.m. on 1/14/17 revealed she had been in-serviced on pureed diets and that the biscuit served for breakfast was pureed. Interview at 8:30 a.m. on 1/14/17 with CNA AG revealed she had received in-services that included pureed diets, diabetic diets, and meal tickets. During an interview on 1/13/17 at 10:35 a.m. with LVN AO she said the facility had provided additional training on pureed foods and resident meal tickets. She said resident meal trays were checked for food consistency and texture, particularly pureed diets. She said all the meal trays were inspected for diets before they were served. She was aware of signs and symptoms of aspiration. During an interview on 1/13/17 at 10:45 a.m. Dietary Staff A said she had received training on therapeutic diets. She said all pureed foods and desserts would now be blended/pureed. She said the bread they served was pureed bread. During an interview on 1/13/17 at 11:00 a.m. the Dietary Manager said she had received additional training on 1/12/17 which included neglect. Additional training had been provided to all dietary staff regarding blended pureed diets, a new check list system for pureed foods and tasting the pureed foods once they were blended for the taste and proper texture. During an interview on 1/13/17 at 12:00 p.m. the Speech Therapist said that when a resident was evaluated and a recommendation of pureed was given, an order was written and a communication form was given to the dietary department. She said she did not specify on the communication form if a resident could have their bread or dessert slurried/covered. She said the form of serving a food item completely slurried/soaked would cause it to be pureed. She said she had not seen bread or cake that was served to residents with pureed diets, served in a form in which it was not soaked completely. Observation on 1/13/17 at 12:00 p.m. of Resident #23 revealed she was seated in her wheelchair in the dining room. Her entire meal, including her bread and her dessert was pureed. Observation on 1/13/17 at 12:15 p.m. of Resident #22 revealed she was seated in her Geri-chair at an assisted feeding table. Her meal of fish, spinach, macaroni and cheese, bread and a chocolate brownie was all pureed. During an interview on 1/13/17 at 12:45 p.m. with CNA AM she said foods had to be blended if the resident was on a pureed diet. They had to match the meal ticket with the meal trays before they were served to the residents. During an interview on 1/13/17 at 5:30 p.m. with CNA BY she was able to differentiate different dietary textures as regular, mechanical and/or pureed. She said pureed diets were blended. Observation on 1/13/17 at 5:50 p.m. CNA CF was in the room of Resident #28 feeding her dinner while the resident was lying in her bed. The head of the bed was raised. Her pureed meal consisted of chicken and dumplings, and vegetables. She had a small bowl of chocolate cake with frosting that was covered with a clear thickened liquid. Before she served Resident #28 the cake she stirred it until it was the same consistency as the pureed foods. During an interview on 1/13/17 at 5:50 p.m. CNA CF said Resident #28 always received t

Based on observation, interview, and record review the facility failed to prevent the development of two stage III pressure sores on the left buttock and right buttock for 1 of 12 residents (Resident #3) reviewed for pressure sores in that: --Resident # 3 developed two facility acquired pressure ulcers to left buttock and right buttocks. The left buttock wound had to be debrided twice. --LVN AO first cleaned the periphery of Resident #3's right and left and right buttock pressure ulcers and did not clean the wound itself. These failures affected 1 resident and placed 8 additional residents with pressure ulcers at risk for developing new pressure ulcers, wound infection, deterioration of the existing pressure ulcers, pain, and a diminished quality of life. Findings included: Resident #3 Record review of Resident # 3's admission sheet revealed she was an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3's Physician order [REDACTED]. Record review of Resident # 3's Admission Braden Scale for Predicting Pressure Ulcer dated 10/13/16 revealed a score of 13 (Moderate risk). Record review of Resident #3's Admission MDS assessment dated [DATE] revealed she had a BIMS score of 13 indicating she was cognitively intact. She required extensive to total assistance of 1 to 2 persons all ADLs. Her skin conditions assessment indicated she had no Pressure ulcers but was at risk of developing pressure ulcers. Record review of Resident #3's Significant Change MDS assessment dated [DATE] revealed revealed she had 1 or more pressure ulcers and was at risk of developing new pressure ulcers. She had 2 unstageable pressure ulcers that had not been present at admission. She had a BIMS score of 11 indicating moderate cognitive impairment. She required extensive to total assistance of 1 to 2 persons all ADLs. Record review of Resident #3's Care Plan dated 10/13/2016 revealed she was care planned for, Impaired skin integrity AEB sacral excoriation and right great toe venous ulcer. Her Care Plan included updates as follows: 12/01/2016 revealed Left buttocks unstageable pressure ulcer, right buttocks stage 2 pressure ulcer. 12/9/2016 revealed change right buttocks to unstageable pressure ulcer. Some specific interventions included: -- treatment as ordered; --nurse will document daily on any aspects of wound healing including but not limited to positioning , nutrition, and hydration, pain, dressing integrity and lab work; --incontinent care as needed; and --turn and reposition every two hours. Observation on 1/11/2017 at 11:00 a.m. revealed LVN AO performed wound care treatment on Resident #3 assisted by CNA Z. LVN AO removed the old dressing from the resident's buttocks. The wound had a moderate amount of drainage and no odor. LVN AO cleaned the surroundings of the wound on the Right and Left Buttock with 4 x 4 gauze soaked in NS but did not clean the wound. LVN AO then applied the Calcium Alginate treatment and covered the wound. During an interview on 1/11/2017 at 11:30 a.m. LVN AO was asked why she did not clean Resident #3's right and left buttock wounds. LVN AO said that she cleaned the wound and that she cleaned the wound from up down through the wound. When she was asked the risk of not cleaning the wound, LVN AO said the wound could be contaminated and deteriorate. Record review of Resident #3's Treatment Administration Record (TAR) for December 2016 record on 01/10/2017 revealed no evidence to show that wound care treatment was provided on the following dates as ordered: -sacral wound on 12/12/2016 and 12/23/2016. -- left buttock wound on 12/12/2016, 12/13/2016, 12/17/2016, and 12/18/2016. --right buttock wound on 12/12/2016, 12/13/2016 and 12/21/2016. Per Wound Care MD on 12/08/2016 .the wound is deteriorating. During an interview on 1/14/17 at 4:40 p.m. the DON said that outside of the wound should be cleaned with one swipe of gauze in a circular motion and the inside also cleaned with one swipe in a circular motion. She said the implication of not cleaning the wounds as ordered by the physician could lead to the spread of infection. The DON did not know why there was no documentation of wound care being provided. During an interview on 1/14/17 at 6:50 p.m. with the MDS Coordinator regarding Resident #3's facility acquired wounds, she said that she used the assessment from the wound care nurse to generate the MDS assessment. She said that the Wound Care Nurse (WCN) assessed the resident's skin on admission and documented that it was excoriation and that was why her admission MDS assessment said the resident had no pressure ulcers but was at risk of developing pressure ulcers. She said yes, Resident #3's current wounds developed in the facility. Record review of Resident #3's January 2017 Physician orders [REDACTED]. Perform head to toe assessment, assess all areas of skin; Skin assessment is to be done weekly; Resident is to be observed by charge nurse every shift; May have therapeutic mattress; Cleanse right buttock with NS, pat dry, apply Calcium Alginate, and cover with dry dressing daily; Cleanse left buttock with NS, pat dry, apply Calcium Alginate, and cover with dry dressing daily; Record review of Resident # 3's Admission Wound Assessment Report dated 10/13/16 and signed by WCN revealed as follows: Wound type - irritation/excoriation Location - Sacrum, Date wound identified - 10/13/2016 Measurement - Length 6.5 cm- Width 8.0 cm-Depth 0.0 cm Record review of Resident # 3's Nurse's Notes dated 12/1/16 and signed by WCN revealed . noted new wounds to left buttock Length 4.5 cm- Width 3.9 cm-Depth 0.3 cm unstageable, right buttock Length 2.9 cm- Width 0.4 cm-Depth 0.1 cm stage 2 . Record review of Resident # 3's Wound Care Physician's consultation report dated 12/1/16 revealed as follows: .Wound #1 - Left buttock Unstageable pressure injury, obscured full thickness skin and tissue loss Pressure Ulcer . Initial wound encounter measurements are - .Length 4.5 cm- Width 3.9 cm-Depth 0.3 cm with an area of 1 There is a moderate amount of drainage noted Wound bed is 40% eschar, 30% slough and 30% granulation . Wound #2 - Right buttock is a Stage 2 pressure injury Pressure Ulcer . Initial wound encounter measurements are - Length 2.9 cm- Width 4.1 cm-Depth 0.1 cm with an area of 11.89 sq cm There is no drainage noted Wound 100% granulation . Further review of Resident # 3's Wound Care Physician's consultation report dated 12/1/16 revealed Wound #1 on her left buttock was surgically debrided and wound orders as follows: Wound #1 - Left buttock - Cleanse/irrigate with Normal saline (NS)/water, Santyl ointment and change dressing every day and as needed. Wound #2 - Right buttock - Cleanse/irrigate with NS/water, apply Duoderm and change dressing every 3 days. Record review of Resident # 3's Admission Care Conference Notes dated 12/13/2016 signed by the Interdisciplinary Team revealed documentation as follows: Skin - Right /Left buttocks unstageable. Record review of Resident # 3's Wound Care Physician' s consultation report dated 12/8/16 revealed: .Wound #2 - Right buttock .is an Unstageable pressure injury, obscured full thickness skin and tissue loss Pressure Ulcer . Subsequent wound encounter measurements are - Length 3.7 cm- Width 4.1 cm-Depth 0.2 cm with an area of 1 There is a moderate amount of sero-sanguinous drainage noted which has an odor Wound bed is 30% [MEDICATION NAME], 40% slough and 30% granulation The wound is deteriorating, periwound skin exhibited maceration. Further review of Resident # 3's Wound Care Physician's consultation report dated 12/8/16 revealed Wound #1 on her left buttock was surgically debrided and wound orders as follows: Wound #1 - Left buttock - Dressing and packing of all wounds demonstrated and performed by Physician; Cleanse/irrigate with Normal saline (NS)/water, Santyl ointment and change dressing every day and as needed. Wound #2 - Right buttock - Dressing and packing of all wounds demonstrated and performed by Physician; Cleanse/irrigate with NS/water, apply Alginate-Calcium Alginate every day and change dressing every day and as needed. Record review of Resident #3's Nurse's Note dated 12/23/16 revealed, .Left buttock stage 3 ulcer .and Right Buttock change to stage 3 ulcer . Record review of the facility's policy and procedure titled Dressings, Dry/Clean revised June 2005 read in part, .Verify that there is a physician order [REDACTED]. if using gauze, use a clean gauze for each cleansing stroke . clean from the least contaminated area to the most contaminated area (usually from the center outward The CMS Form 672 listed 9 residents in the facility as having pressure ulcers.