Every finding on record at Good Samaritan Society - Larimore

Based on record review, review of facility policy, and staff interview, the facility failed to provide necessary care and services for 1 of 1 closed record resident (Resident #4) reviewed. Failure to assess, monitor blood pressures, and implement interventions in response to Resident #4's low blood pressure may have contributed to the resident's decline in condition. Findings include:Review of the facility policy titled Vital Signs - Blood Pressure occurred on 05/19/26. This policy, dated 11/12/25, stated, . PURPOSE To assess whether resident's blood pressure is within normal limits . Record vital signs. Report to the nurse if the blood pressure is . below 90/60, or the resident is complaining of light headedness, dizziness, blurred vision and/or shallow breathing.Review of Resident #4's medical record occurred on 05/19/26 and identified an admission date of 04/10/26. Diagnoses included hypertension (high blood pressure). Physician orders included the following:* Hydrochlorothiazide 25 milligrams (mg) daily for hypertension* Clonidine 0.1 mg two times a day for hypertension* Benazepril 20 mg daily for hypertension* Atenolol 100 mg daily for hypertensionReview of Resident #4's progress notes showed the following:* 04/15/26 at 5:15 p.m., . Call received from MDS [Minimum Data Set] nurse informing this writer that res [resident] was being sent out for ER [emergency room] eval [evaluation] at request of family d/t [due to] lethargy.* 04/15/26 at 5:18 p.m. Nurse was called in to resident's room by family members (wife, daughter and son). Upon entering room resident was noted to be lethargic, but easily arouse.[sic]. He was able to communicate with nurse in a slow/soft voice. His vital signs when checked were: 98.0, [temperature] 78 [pulse], 14 [respirations], 79/38 [blood pressure] Lying RA [right arm] 110/55 Lying LA [left arm] 90% RA [room air], with no s/s [signs or symptoms] of SOB [shortness of breath] at rest, Blood sugar 168 mg/dL [milligrams per deciliter]. Primary provider was called, and updated about resident's status, who gave order for resident to be sent to the emergency room [ER] for further evaluation. Nurse updated family members, prior to placing 911 call. Wife refused to signed [sic] bed hold at this time. Paramedic crew arrived about 30 minutes later, and took resident to the ER.Review of Resident #4's blood pressure readings showed the following:* 04/10/26 at 12:39 p.m. 135/73* 04/11/26 at 1:52 p.m. 108/58* 04/11/26 at 2:14 p.m. 98/58 * 04/15/26 at 4:35 p.m. 79/38 During an interview on 04/19/26 at 4:10 p.m. an administrative nurse (#1) stated she expected the medication aide who took Resident's #4's blood pressure on 04/11/26 to report the low blood pressure to the nurse. The administrative nurse also stated, When a resident is on daily skilled notes, nursing should absolutely be taking their blood pressure daily.The facility failed to follow up/intervene when Resident #4's blood pressure fell below normal limits on 04/11/26 until the family alerted facility staff of the resident's lethargy on 04/15/26.

Based on observation, review of facility policy, and staff interview, the facility failed to serve foods at a palatable temperature for 1 of 1 kitchen (tray cart to be served in parlor area). Failure to serve foods at a palatable temperature may result in decreased intake, weight loss, and inadequate nutrition.Findings include: Review of the facility policy titled Room-Tray Service-Food and Nutrition occurred on 03/17/26. This policy, revised March 2025, stated, . General . 6. Periodically monitor room/tray service to ensure quality and timeliness of service and compliance with food temperature standard. - Observation on 03/16/26 at 9:40 a.m. showed a cart containing food trays in the parlor area and Resident #10 was eating his meal. Facility staff served Resident #15 his meal tray of eggs and toast at 9:45 a.m. When asked if his breakfast food was warm, Resident #15 stated, No. Resident #10 said his food was also cold and stated, That's an everyday occurrence. Resident #28 received his tray at 9:50 a.m. and when asked about his meal, Resident #28 stated his eggs were cold. - Observation on 03/17/26 at 09:05 a.m. showed an unidentified dietary staff member placed covered room trays in the meal tray cart. A dietary staff member (#9) delivered the cart to the parlor area. A nursing staff member served the first room tray at 9:14 a.m. and the last tray at 9:44 a.m. A taste test conducted by the surveyors confirmed the food items were cold. - Observation on 03/18/26 at 9:15 a.m. showed a dietary staff placed food trays in the meal tray cart for delivery. At 9:50 a.m., a dietary staff member (#9) stated an administrative staff member (#10) asked her to check the temperatures on the tray cart because of the delay in delivery. The dietary staff member returned the meal tray cart to the kitchen and stated the kitchen staff will prepare warm food for the residents. During an interview on 03/18/26 at 4:05 p.m., an administrative staff member (#9) stated that the expectation is that certified nurse aides (CNA) serve the food trays immediately as there is an aide for each hallway and staff check food temperatures when there is a concern with late service/delivery.

Based on observation, record review, review of the Resident Council meeting minutes, review of the facility bathing schedule, review of facility policy, and resident and staff interviews, the facility failed to ensure residents received the necessary services to maintain good grooming for 3 of 14 sampled residents (Residents #2, #3, and #36) and 1 supplemental resident (Resident #33) observed with unkempt hair and beards. Failure to ensure residents receive assistance with haircuts, grooming, and bathing may decrease the resident's self-esteem and quality of care. Findings include: Review of the facility policy titled Routine Practice occurred on 03/18/26. This policy, dated October 2025, stated, . Routine practices are services that are expected to be provided to all residents based on accepted, clinical guidelines and resident status and are not detailed on the care plan . Anticipate and meet needs . Baths/showers per week . Will be kept clean and free from odors . Review of the facility admission packet form titled Hair Care occurred on 03/18/25. This form identified the following options: * I would like hair care provided to me/my family member by a liscensed [sic] beautician. I understand that there is an additional charge. * I understand that the facility pays for one haircut every 4-6 weeks. Review of the Resident Council meeting minutes, dated 01/20/26, stated, . Residents asked if we will have a new beauty operator. - Observation on 03/15/26 at 4:00 p.m. showed Resident #3 with long hair. When asked how the resident prefers to wear his hair, Resident #3 stated, They don't have anyone [beautician] to give haircuts anymore. It's been a long time. -Observation on 03/16/26 at 10:10 a.m. showed Resident #2's hair over the tops of both ears. When asked how the resident prefers to wear his hair, Resident #2 stated, I could use a cut. It's been a while. -Observation on 03/16/26 at 10:53 a.m. showed Resident #33's hair over the tops of both ears and bangs covered a large portion of the left side of his face. When asked how the resident prefers to wear his hair, Resident #33 stated, I could use a cut. They used to have some lady do it but she hasn't been here for a while. During an interview on the afternoon of 03/18/26, an administrative staff member (#13) stated a beautician has not been in the facility since 12/22/25 and currently the facility does not have one. Review of the Resident Council meeting minutes, dated 02/03/26, stated, . several residents reported not receiving their weekly baths on schedule. -Review of Resident #36's medical record occurred on all days of survey. The current care plan identified extensive assistance of one staff member required for bathing and personal hygiene. Observation on 03/15/26 at 1:40 p.m. showed Resident #36 with long hair, a beard with thick hair growth on his neck, and food in the lower beard along the lip line. A certified nurse aide (CNA) (#12) assisted the resident with toileting but failed to offer assistance to clean his face. Review of the facility bathing scheduled identified Resident #36 receives a bath on Wednesdays. Review of the bathing documentation, from 03/04/26 through 03/18/26, identified the resident received a whirlpool bath on 03/04/26 and on 03/18/26 (13 days without a bath). The medical record failed to identify Resident #36 refused a bath or if the facility rescheduled the bath that should have occurred on 03/11/26. During an interview on 03/16/26 at 4:14 p.m., an administrative staff member (#1) stated if a bath isn't completed on a resident's scheduled day, she expects the charge nurse to discuss with the resident if it is Ok to have their bath on a different day, and the nurse to document the conversation in the resident's progress notes. During an interview on the morning of 03/17/26, a CNA (#6) stated bath aides shave the residents on their bath day.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment for 4 of 14 sampled residents (Resident #7, #10, #24, and #25) reviewed for advanced directives/code status. Failure to ensure the medical record and other forms of communication accurately reflected the code status discussed and agreed upon by the resident and/or the resident's legal representative limits the facility's ability to communicate to direct care staff and emergency personnel their wishes in the event of a medical emergency. Findings include: Review of the facility policy titled Advanced Care Planning occurred on [DATE]. This policy, dated [DATE], stated, . Advanced Directive: A written instruction . relating to the provision of healthcare when the individual is incapacitated. Informed Consent: The granting of permission by the resident and/or his or her legal representative . At the time of admission . staff . will inform the resident/healthcare decision-maker of the right to consent to or refuse medical treatment . all advance care planning discussions . must be documented in the medical record . Advanced directive orders are to be reviewed with resident/healthcare decision-maker at each care plan meeting . -Review of Resident #7's medical record occurred on all days of survey. A physician's order, dated [DATE], indicated cardiopulmonary resuscitation (CPR-full code status). The record lacked documentation the resident or representative agreed with the code status. -Review of Resident #10's medical record occurred on all days of survey. A physician's order, dated [DATE], indicated CPR. When asked for documentation showing the resident or their representative agreed with the code status, the facility provided a document signed by the resident and dated [DATE] (date during the survey). -Review of Resident #24's medical record occurred on all days of survey. A physician's order, dated [DATE], indicated CPR. The record lacked documentation the resident or their representative agreed with the code status. -Review of Resident #25's medical record occurred on all days of survey. A physician's order, dated [DATE], indicated CPR. The record lacked documentation the resident or their representative agreed with the code status. During an interview on [DATE] at 9:28 a.m., a management staff member (#8) confirmed staff failed to obtain signed documentation regarding the resident/resident representative's wishes regarding code status.

Based on observation, review of professional reference, and staff interview, the facility failed to ensure safe and secure storage of medications and/or private health information on 1 of 1 medication cart and failed to ensure medication labels matched provider's orders for 2 of 5 residents (Resident #18 and #19) observed during medication pass. Failure to secure medications and electronic health information may result in unauthorized access and failure to ensure medication labels matched the provider's orders placed residents at risk for medication errors.Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 838-840, stated, . Obtain the appropriate medication. Compare the label of the medication container or unit-dose package against the order on the MAR [medication administration record] or computer printout. Rationale: This is a safety check to ensure that the right medication is given. If these are not identical, recheck the prescriber's written order in the client's chart. If there is still a discrepancy, check with the pharmacist. Prepare the medication. While preparing the medication, recheck each prepared drug and container with the MAR again. Rationale: This second safety check reduces the chance of error. Lock the medication cart before entering the client's room. Rationale: This is a safety measure because medication carts are not to be left open when unattended.-Observations of the medication cart showed the following: *03/15/26 at 10:15 a.m., the cart located in the hallway outside the nurse's station unlocked and unattended for approximately 5 minutes in a high traffic area with staff and residents present. *03/16/26 at 8:07 a.m., the cart located in the 200 hallway unlocked, unattended, and the electronic medication administration record (eMAR) visible to staff and residents. Observation showed a resident attempting to get around the cart.-Observations on 03/17/26 during medication pass identified the following:*8:41 a.m., a nurse (#11) prepared Resident #18's medications. The eMAR identified pantoprazole 40 milligrams (mg) daily. The medication label indicated to administer the medication 30 minutes before breakfast. The eMAR failed to include to administer before breakfast. *4:13 p.m., a medication aide (MA) (#7) prepared Resident #19's medications. A provider's order in the eMAR identified pantoprazole 40 mg daily at 5:00 p.m. The medication label indicated to administer the medication at 9:00 a.m. and 9:00 p.m. (twice a day). The facility failed to ensure safe and secure storage of medications and private health information and failed to ensure the medication labels and provider's orders in the eMAR correspond. During an interview on 03/17/26 at 11:42 a.m., a staff nurse (#11) confirmed Resident #18 and #19's pantoprazole medication labels do not match the residents' eMARs.

Based on observation, record review, and review of facility policy, the facility failed to provide appropriate respiratory care for 1 of 2 sampled residents (Resident #25) with orders for continuous oxygen. Failure to administer oxygen according to the physician's orders resulted in Resident #25 experiencing low oxygen saturation levels (level of oxygen circulating in the blood) and may compromise the resident's respiratory status. Findings include:Review of the facility policy titled Oxygen Administration, Safety, Mask Types occurred on 03/28/26. This policy, dated 07/30/25, stated, . Oxygen therapy is carried out only with a medical provider order. A licensed nurse or other employee trained . in the use of oxygen . will be . responsible for the proper administration of oxygen to the resident.Review of Resident #25's medical record occurred on all days of survey. A physician's order, dated 01/28/26, identified continuous oxygen via nasal cannula for oxygen saturation less than 88% (percent) for shortness of breath and low oxygen saturation levels. Observation on 03/15/26 at 2:04 p.m. showed Resident #25 seated in a wheelchair in her room. A certified nurse aide (CNA) (#4) removed the nasal cannula from the resident's nose, assisted the resident from the wheelchair to the toilet, and from the toilet back to the wheelchair. The resident appeared short of breath, and the surveyor asked the CNA (#4) to call the nurse to the room to assess the resident's respiratory status. At 2:30 p.m., a nurse (#3) entered the room, obtained an oxygen saturation reading of 82%, and the CNA (#4) applied the cannula into the resident's nostrils. At 2:37 p.m., Resident #25's oxygen saturation level varied between 92% and 94%. The facility staff failed to follow the physician's orders and left Resident #25 without oxygen for 26 minutes during transfers/toileting.

Based on record review and staff interview, the facility failed to inform 3 of 5 sampled residents (Resident #2, #7, and #17) or their representative on the risks and benefits related to the use of psychotropic medications. Failure to inform the resident or representative of the risks and benefits of psychotropic medication does not allow them to make an informed decision regarding his/her treatment options.Findings include: -Review of Resident #2's medical record occurred on all days of survey. A physician's order, dated 02/04/26, identified Zoloft (an antidepressant) daily. The record lacked evidence the facility informed Resident #2 or the resident representative of the risks and benefits associated with the use of the psychotropic medications. - Review of Resident #7's medical record occurred on all days of survey. A physician's order, dated 03/25/25, included Trazodone (an antidepressant) at bedtime. The record lacked evidence the facility informed Resident #7 or the resident representative of the risks and benefits associated with the use of the psychotropic medications.- Review of Resident #17's medical record occurred on all days of survey. A physician's order, dated 02/22/25, included Cymbalta (an antidepressant) daily. The record lacked evidence the facility informed Resident #17 or the resident representative of the risks and benefits associated with the use of the psychotropic medications. During an interview on the afternoon of 03/17/2026, an administrative nurse (#2) confirmed Resident #2, #7, and #17's records lacked documentation the residents or their representative received information related to the risks and benefits associated with the use of psychotropic medications.

Based on observation, record review, and review of facility policy, the facility failed to utilize assistive devices necessary to ensure safe transfers for 1 of 2 sampled residents (Resident #25) observed during gait belt and/or pivot transfers. Failure to utilize appropriate devices for safe transfers placed Resident #25 at risk of injury and/or falls.Findings include:Review of the facility policy titled Gait-Transfer Belt occurred on 03/18/26. This policy, dated 05/06/25, stated, . PURPOSE: To safely stabilize a transfer . To aid residents in maintaining balance. Do not use the pants/slacks belt as a gait (Transfer) belt.Review of Resident #25's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident does not walk due to safety concerns and required partial to moderate staff assistance with transfers. The care plan identified assistance of one staff member for transfers, toilet use, and personal hygiene related to weakness. Observations on 03/15/26 showed the following:*2:04 p.m., A certified nurse aide (CNA) (#4) placed a gait belt around Resident #25's waist and assisted the resident to pivot transfer from the wheelchair to the toilet, from the toilet to the wheelchair, and from the wheelchair to the bed while pulling on the gait belt and the back of the resident's pants. During each of the transfers, Resident #25's legs unsteady. *2:42 p.m., Resident #25 positioned diagonally in bed and activated the call light. A nurse (#3) answered the light, and when unable to locate a gait belt, placed an arm around the resident's back, assisted the resident to sit on the edge of the bed, placed a four-wheeled rolling walker in front of the resident, and asked her to stand. As the resident stood up, her legs were unsteady and the walker rolled away as she sat on the bed. The facility staff failed to utilize a gait belt to ensure safe transfers for Resident #25.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 14 sampled residents (Resident #2 and #3). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30-32, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510 . Section A1510 . Coding instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . Review of Resident #2's medical record occurred on all days of survey and identified diagnoses of bipolar disorder and major depression since 2018. An annual MDS, dated [DATE], showed the facility failed to code Sections A1500 and A1510 for serious mental illness. During an interview the morning of 03/17/26, an administrative staff member (#2) confirmed the facility failed to correctly code Section A. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2025, page N-8, stated, . Coding Instructions . N0415J1: Hypoglycemic (including insulin) . Check if a hypoglycemic medication was taken by the resident at any time during the 7-day observation period. N0415K1: Anticonvulsant: Check if an anticonvulsant medication was taken by the resident at any time during the 7-day observation period. Review of Resident #3's medical record occurred on all days of survey. Current medications included Metformin (a hypoglycemic medication) twice a day and Gabapentin (an anticonvulsant) four times a day. The quarterly MDS, dated [DATE], showed the facility failed to code the hypoglycemic and anticonvulsant medications. During an interview on 03/18/26 at 10:30 a.m., an administrative staff member (#2) confirmed the facility failed to correctly code Section N.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident and/or representative of emergency room transfer for 1 of 5 sampled residents (Resident #9) reviewed for hospitalizations. Failure to inform the resident and/or their representative of a transfer does not allow for informed decisions regarding care. Findings include:Review of the facility policy titled Discharge and Transfer Rehab/Skilled, Therapy & Rehab occurred on 03/17/26. This policy, revised January 2026, stated, . 1. Notify the resident and the resident's representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand .Review of the facility form Hospital Transfer Checklist occurred on 03/17/26. The checklist states, . Notify family or guardian. Document in progress notes or in the . CICE [change in condition evaluation] .Review of Resident #9's medical record occurred on 03/17/26 and identified a transfer to the hospital on [DATE]. The facility failed to provide a written transfer notice to the resident and/or representative.During an interview on 03/16/26 at 4:10 p.m., an administrative staff member (#1) confirmed the facility failed to notify the resident's representative of the transfer.

Based on record review, review of facility policy, and staff interview, the facility failed to provide appropriate discharge planning to the resident or their representative for 1 of 2 closed records (Resident A reviewed for discharge. Failure to document the basis for Resident A's transfer and discharge in the medical record does not allow the resident and/or their representative to make informed decisions regarding their further care needs.Findings include:Review of the facility policy titled Discharge and Transfer occurred on 03/18/26. This policy, dated January 2026, stated, . Policy. The location permits each resident to remain in the location and does not transfer or discharge the resident from the location unless . The safety of individuals in the location is endangered due to the clinical or behavioral status of the resident. The basis for the transfer must be documented in the resident's record by a physician.Review of Resident A's medical record occurred on 03/18/26. Diagnoses included anxiety, depression, and a cerebral infarction (stroke). Medications included Melatonin (sleep aide), and Zoloft, an antidepressant initiated in April 2025 for a change in behaviors and anxiety.The current care plan included the following:*Initiated on 11/02/21, The resident wishes to remain in center [nursing facility] due to his needs for nursing care. Interventions included, Establish a pre-discharge plan with resident/family and evaluate progress and revisit plan (FREQ) [frequently].*Initiated on 10/05/24, The resident has displayed inappropriate sexual advances towards another resident and staff. Interventions included, Touching female resident: tell him to stop, immediately re-direct and report to nurse, and SEXUALLY INAPPROPRIATE: Monitor resident Q [every] 30 minutes. The care plan failed to identify an imminent discharge need due to behavioral changes.Resident A's progress notes included the following:*04/30/25 . Resident is alert and oriented. Mood is stable. [Family] visits often and helps make healthcare and financial decisions. Resident has previously had instances of inappropriate touching to female residents . Care plan reflects interventions. No recent occurrences. Discharge plan is to remain in center. *06/18/25 . Conversation with [Resident] about report of him attempting to grab between CNAs [certified nurse aide] leg/inner thigh. Reminded him this is not appropriate. Resident stated 'okay.' .*08/04/25 at 5:58 a.m. Resident grabbed CNA . during AM cares this morning. Was redirected and reminded it is inappropriate behavior. *08/04/25 at 3:24 p.m. Care Conference Note. All in attendance . [Family] . Off schedule care conference to discuss residents noted behavior. Will request a psych [Psychiatric] referral .*08/07/25 . Resident seen by [Physician] on rounds. Referral to Psych for consult.*08/26/25 Seen by . Rural Psych for inappropriate behaviors. New order for [increase in antidepressant medication dosage] .*08/28/25 at 11:39 a.m. Discharge Planning/Discharge. Resident sent to [medical facility] per [Physician] request. [Family] signed discharge form.*08/27/25 at 4:24 p.m. Late Entry Discharge Planning/Discharge Note Text: Resident referral sent to multiple facilities searching for placement.The medical record identified no inappropriate from 08/05/25 through 08/25/25.The medical record showed the facility transferred and discharged Resident A to an acute care hospital and subsequently discharged from the facility on the same day, 08/28/25. During an interview on 03/18/26 at 3:50 p.m. an administrative staff member (#8) confirmed the progress notes identified the facility sent referrals to various facilities for placement, however, could not provide the referral documents to show the number of facilities contacted, when they were contacted, and why they were unable to accommodate the resident's needs. The facility failed to assess Resident A's behaviors, monitor behaviors after a change in medication, revise the discharge plan, and consistently document the ongoing safety threat posed to other residents that would require an immediate discharge from the facility.

Based on observation and review of the Resident Council meeting minutes, the facility failed to provide privacy and ensure dignity during personal cares for 1 of 7 sampled residents (Resident #25) observed during personal cares. Failure to maintain a resident's privacy during cares is a violation of residents' rights and may decrease the resident's self-esteem and quality of life.Findings include:Review of the Resident Council meeting minutes occurred on all days of survey. The minutes, dated 12/10/25, stated, Staff should knock on the door, then wait for a response. They knock and come right in, even in the tub room. The minutes, dated 01/20/26, stated, Staff does consistently knock before entering rooms but sometimes don't wait long enough for a response.Observation on 03/15/26 at 2:04 p.m. showed a certified nurse aide (CNA) (#4) transferred Resident #25 from a wheelchair to the toilet to provide toileting cares. On two separate occasions, unidentified staff members knocked on the resident's room door, immediately opened the door, and began to enter the room. Both times, the staff noticed the surveyor in the room, stated, oh, closed the door, and left. Later, a CNA (#7) knocked on the resident's room door, immediately entered the room, and walked into the bathroom. When the CNA (#7) noticed Resident #25 on the toilet, the CNA backed out of the bathroom, knocked on the bathroom door, stated I just need to check something, reentered the bathroom, and reached for a container on a shelf above the toilet. The two unidentified staff members and the CNA (#7) failed to wait for acknowledgment from the CNA (#4) or Resident #25 before they entered the resident's room and bathroom.

Based on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 5 residents (Resident #18 and #19) observed during medication administration. Two medication errors occurred during staff administration of 25 medications, resulting in an eight percent error rate. Failure to administer medications at the correct time may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.Findings include:Prescribing information for levothyroxine (treats thyroid disorders), revised April 2019, found at https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021116s017lbl.pdf, stated, . 2.1 General Administration Information Administer Levothyroxine Sodium Tablets as a single daily dose, on an empty stomach, one half to one hour before breakfast. Review of the facility policy titled Medication Administration Including Scheduling and Medication Aides occurred on 03/18/26. This policy, dated 04/08/25, stated, . Medication Administration . Follow the 'Six Rights': . Right Time . Observations on 03/17/26 during medication administration showed the following: *8:21 a.m., A nurse (#11) administered Resident #22's levothyroxine along with other scheduled morning medications, assisted the resident to the dining room, and the resident ate breakfast shortly after. *A nurse (#11) removed a 4% lidocaine pain patch from a box, entered Resident #18's room, and applied the patch to the resident's lower back. The provider's orders indicated to apply the patch to the resident's back at bedtime and remove the patch in the morning. (The patch from the previous evening was not present on the resident's back).During an interview on 03/17/26 at 11:42 a.m., the nurse (#11) confirmed he/she failed to administer the levothyroxine at least 30 minutes before breakfast on an empty stomach and failed to follow provider's orders when applying the lidocaine patch.

Based on observation and staff interview, the facility failed to post accurate and complete staffing information on 2 of 2 weekend days (March 14-15, 2026) reviewed. Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift. Findings include:Observation on 03/15/26 at 12:15 p.m. showed staff postings for Thursday 03/12/26 and Friday 03/13/26. The facility failed to update the number of licensed and unlicensed staff working on the days of Saturday 03/14/26 and Sunday 03/15/26.During an interview on 03/15/26 at 12:30 p.m., a charge nurse (#3) confirmed the facility failed to update the staffing information for Saturday and Sunday.

Based on observation, review of facility policy, and staff interview, the facility failed to monitor temperatures and follow safe storage practices for 1 of 3 freezer units. Failure to keep freezer temperatures at 0 degrees Fahrenheit or below and monitor freezer temperatures may increase the likelihood of food borne- illnesses.Findings include: Review of the facility policy titled Food-Supply Storage-Food and Nutrition Services occurred on 03/18/26. This policy, revised March 2026, stated, Procedure. 13. In the freezer, the temperature is 0 degrees Fahrenheit or lower. The freezer . 14. internal temperatures of all freezers in the food and nutrition department, dining room, and nourishment areas are recorded twice daily . Review of the untitled facility document provided by administrative staff member (#9) on 03/18/26 showed lack of documentation for monitoring freezer temperatures of the freezer located in the parlor area from 12/01/25 through 03/09/26. - Observation of the parlor area freezer unit on 03/17/26 at 11:15 a.m. showed the freezer temperature at 6 degrees Fahrenheit. The staff member (#9) removed and disposed of the remaining food from the freezer. During an interview on 03/18/26 at 4:05 p.m., an administrative staff member (#9) stated he/she expected freezer temperatures at 0 degrees Fahrenheit or below.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) meeting sign in sheets, and staff interview, the facility failed to ensure all required members attended meetings at least quarterly for 2 of 4 quarters (November 2025 and February 2026) reviewed. Failure to have the medical director participate in the facility's quality assurance activities may result in an ineffective QAPI program and deprives the committee of the physician's unique contributions for analysis of quality concerns and assisting with decision making based on identified concerns.Findings include:Review of the QAPI meeting sign-in sheets, from March 2025 to February 2026 showed the medical director failed to attend any meetings since August 2025.During an interview on 03/18/26 at 3:30 p.m., an administrative staff member (#8) confirmed that the medical director failed to attend the required quarterly QAPI committee meetings.

Based on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of infection control and prevention for 1 of 2 sampled residents (Resident #24) on enhanced barrier precautions (EBP) and 1 supplemental resident (Resident #22) during medication administration. Failure to practice infection control standards related to hand hygiene and glove and gown use has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 03/18/26. This policy, dated 11/13/25, stated, . HCW [healthcare worker] will use waterless alcohol-based sanitizer or soap and water to clean their hands: When entering the patient room. Before . administering medications. hand hygiene must be completed before donning gloves. After removing gloves . When exiting patient room. Review of the facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions occurred on 03/18/26. This policy, dated July 2025, stated, . Enhanced barrier precautions expand the use of personal protective equipment . the use of gown and gloves during high contact care activities. Enhanced barrier precautions are used . for residents with chronic wounds . venous statis [sic] ulcers [chronic wounds due to poor blood circulation in veins] . High-contact resident care activities include transfers . providing hygiene, changing briefs or assisting with toileting. -Review of Resident #24's medical record occurred on all days of survey. The care plan identified EBP related to chronic venous stasis ulcers. Observation on 03/16/26 at 11:10 a.m. showed a certified nurse aide (CNA) (#4) entered Resident #24's room, performed hand hygiene, applied gloves, and assisted the resident with toileting. The CNA failed to wear a gown during high contact cares. -Observation on 03/17/26 at 8:21 a.m. showed a nurse (#11) prepared Resident #22's medications, carried them into the resident's room, and administered the oral medications. Without performing hand hygiene, the nurse applied gloves, administered eyes drops, removed the gloves, and without performing hand hygiene, exited the resident's room. During an interview on 03/17/26 at 11:42 a.m., the nurse (#11) confirmed he/she failed to appropriately perform hand hygiene during Resident #22's medication pass.

Based on record review, facility policy/procedure review, and staff interview, the facility failed to provide the necessary treatment/services to promote healing and prevent the worsening of pressure ulcers for 2 of 2 sampled residents (Residents #2 and #3) with pressure ulcers. Failure to consistently implement interventions to prevent worsening of an existing pressure ulcer and identify changes resulted in delayed treatment and deterioration of the resident's pressure ulcers. Findings Include:Review of the facility policy titled, Physician/Practitioner Orders occurred on 11/05/25. This policy, dated 04/06/25, stated, . PURPOSE: To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. To provide a procedure that facilitates the timely and accurate processing of physician/practitioner orders . POLICY: Verbal/Telephone orders will be taken only by a licensed nurse . who will enter the order promptly into PCC [point click care-electronic medical record] . PROCEDURE: Physician/Practitioner orders are a critical component to providing quality care to residents. The nursing services and health information management (HIM) departments each have responsibilities for processing physician/practitioner orders in a timely and accurate manner.The facility failed to provide a policy for processing referrals to an outside agency.- Review of Resident #2's medical record occurred on 11/05/25 and identified an admission date of 10/16/25. A nursing note, dated 10/16/25 at 2:57 p.m., stated, . Resident admitted from . Hospital . Res [resident] has pressure ulcers to left ankle and sacrum. The care plan identified, . The resident has 2 pressure ulcers on admit - coccyx and ankle. An intervention, dated 10/27/25, stated, . Encourage, assist, supervise with use of assist bar, trapeze bar, etc. for resident to assist with turning. Physician's orders, dated 10/31/25, included:*Rotate (reposition) every two hours*Prevalon (protective padded boot) boot when in bedThe medical record failed to show staff repositioned Resident #2 every two hours and applied the Prevalon boots as ordered. During an interview on 11/05/25 at 5:02 p.m., an administrative staff member (#1) confirmed Resident #2's medical record lacked documentation of repositioning and application of Prevalon boots.- Review of Resident #3's medical record occurred on 11/05/25 and identified and admission date of 9/12/25 with a diagnosis of spinal cord compression. The physician's admission orders failed to identify a pressure ulcer or pressure ulcer treatment. On 9/16/25 (4 days after admission) a nursing note identified deep tissue injuries (DTI) (pressure-induced damage to underlying tissues) to both buttocks. The facility obtained wound care orders on 09/17/25. Modifications to wound care orders occurred on 09/26/25, 10/09/25, and 10/20/25.Resident #3's care plan identified assistance of two staff members required for bed mobility. A wound assessment, dated 09/25/25, stated to reposition the resident every 2-3 hours and as needed (PRN) however, the facility failed to add this intervention to the care plan until 10/15/25, approximately one month after identifying the DTI.The medical record lacked evidence staff repositioned Resident #3 every 2-3 hours and as needed.Review of Resident #3's medical record identified the following:*09/16/25 . DTI to R) [right] buttock . Length 3.2 cm [centimeter] . Width 1.1 cm . Calmoseptine [an ointment used to treat skin irritations] and Mepilex [an absorbent dressing] apply 3x/week [three times per] and PRN. The nurse identified the assessment as the initial assessment.*09/25/25 . DTI on both buttocks . Length 3.2 cm . Width 1.1 cm . Depth 0.1 cm . L) [left] buttock 4.4 cm x [by] 3 cm x 0.2 cm .*10/02/25 . Pressure ulceration . Length 4 cm . Width 3.5 cm . Depth 0 cm . Is drainage present on the dressing? Yes. Is there drainage leaking around the dressing? Yes. Describe the condition of tissue surrounding the dressing: Purulent [a thick fluid that is a sign of infection]. Describe: Purulent, blackening tissue, malodorous [unpleasant smell] . Additional information . Dr [name] office contacted in regards to concerns of wound complication. Awaiting further orders .*10/04/25 . Pressure ulcer progressed and both buttocks open . Length 9 cm .Width 8 cm . Depth 0.2 cm . ulcer to noted to be progressed and size increased from last assessment . Comments: . Pro Source . BID [twice a day] to enhance wound healing . Dr. [name] updated on wound progressing . (The bilateral buttock wounds merged into one sacral wound at this point).*10/07/25 at 9:43 a.m. Communication/Visit with Physician Late Entry: . Dr [name] at bedside visiting with resident . Review of the provider visit note failed to include reference of any skin issues or pressure ulcers.*10/08/25 . Pressure ulcer to Sacrum/buttocks . Comments: Fax sent to Dr. [name] wit [sic] wound updated to obtain order for wound clinic VA [veterans administration] referral . *10/11/25 at 5:40 p.m. Health Status . Late Entry: [entered into the electronic medical record on 10/24/25 at 12:18 p.m.] . Received order to refer resident to VA for wound care. Order entered and left voicemail for social worker to schedule appointment.*10/18/25 Wound name . Unstageable pressure ulcer to buttock/Sacrum area . Length 6.7 cm . Width 6 cm . Comments: resident encouraged to reposition self .*10/20/25 . unstageable p/u [pressure ulcer] with tunneling to Sacrum area. Is there drainage leaking around the dressing? Yes. Describe the condition of tissue surrounding the dressing: macerated [soft and draining due to moisture exposure] and reddened. Is there a presence of possible complications .? Yes . Describe: increasing drainage, odor, slough [shedding of dead tissue], and necrotic [dead] tissues and tunneling . Describe dressing . Calcium alginate [an absorbent dressing] and Mepilex . Comments: Resident sent to . ER [emergency room] via ambulance .An emergency room note, dated 10/20/25, identified Resident #3 presented with ulcers and pain. The resident was hospitalized with a stage 4 (the most severe type of pressure ulcer involving deep tissue damage, exposing muscle, tendon, or bone) pressure injury of the buttocks and acute cellulitis (bacterial skin infection that affects the deeper layers of the skin).During an interview on 11/5/25 at 4:00 p.m., an administrative staff member (#1) confirmed nursing staff failed to follow up with the requests for Resident #3's wound clinic referrals sent to the provider on 10/2/25 and 10/8/25, confirmed the provider failed to evaluate the resident's wound on 10/07/25, confirmed there were nine days between Resident #3's wound clinic referral order and coordination of the referral, and the medical record lacked documentation of repositioning. The facility failed to implement a repositioning schedule and ensure wound care follow up in a timely manner which resulted in deterioration of Resident #3's pressure ulcers.

Based on record review, review of the facility reported incident (FRI), and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell during a staff assisted transfer. Failure to utilize the gait belt resulted in Resident #1's fall/fracture and placed all residents transferred with a gait belt at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.Findings Include:The surveyor determined a deficient practice existed on 06/17/25. The facility implemented corrective action immediately and completed corrective action on 07/07/25. Review of the facility policy titled Gait Belt-Therapy & Rehab occurred on 07/09/25. This policy, dated September 2024, stated, Gait belts are used to aid patients during transfers and/or ambulation. The gait belt provides a firm grasping surface for the healthcare provider, protects the patient from accidental trauma, and helps reduce healthcare provider injury.Review of the initial FRI, dated 06/17/25, stated, Resident had a fall at this time. CNA [certified nurse aide] [#1] called nurse on walkie to let this nurse know that resident had an assisted fall to the floor during transfer from wheelchair to recliner. Resident was being transferred with 1 staff assist and states that her knees gave out. Resident assisted into recliner with hoyer [mechanical] lift and 2 staff assist. CNA reported that she observed resident hitting her head on dresser. Review of Resident #1's medical record occurred 07/09/25. Diagnoses included right hip fracture. The care plan stated, . The resident has an ADL [activities of daily living] self-care performance deficit R/T [related to] weakness E/B [evidenced by] need for assist . TRANSFER: Resident requires assist of 1 .Resident #1's progress notes, dated 06/17/25, stated, at 8:21 p.m., . Resident had a fall at this time. At 10:05 p.m. Resident sent to ER [emergency room] at this time for 10/10 [a numerical pain rating] pain in R) hip.The facility failed to ensure staff utilized a gait belt while assisting Resident #1. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the following corrective actions to ensure all residents affected by the deficient practice were transferred in an appropriate manner:* Completed an investigation into Resident #1's fall/right hip fracture.* Educated CNA (#1) following the incident on 06/17/25 and 06/30/25.* Provided staff education regarding staff-assisted transfers/gait belt use via electronic messages and/or posted memos on 06/25/25 and 07/07/25.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#9) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 02/10/25 at 1:52 p.m., the dietary manager (#9) stated he is currently enrolled in a certified dietary manager course but has not completed it. The facility failed to ensure the dietary manager (#9) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 2 sampled residents (Resident #81) with weight loss. Failure to routinely monitor and evaluate weights, ensure timely weight loss interventions and consistently implement them, accurately document intakes, and periodically review existing interventions and evaluate the need for updated interventions resulted in continued weight loss for Resident #81. Findings include: Review of the facility policy titled Weight and Height occurred on 02/01/24. This policy, dated 09/18/23, stated, . PURPOSE . To ensure that the resident maintains acceptable parameters of nutritional status regarding weight . To monitor weight loss or gain in a resident . All residents are weighed at a minimum of weekly for the first four weeks following admission . Residents at nutritional risk will be weighed weekly . Review of the facility policy titled Nutrition and Hydration - Food and Nutrition occurred on 02/01/24. This policy, dated 04/12/23, stated, . POLICY: The location ensures that each resident maintains acceptable parameters of nutritional status such as usual body weight or desirable body weight range and electrolyte balance unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Provide nutritional care and services to each resident, consistent with the resident's comprehensive assessments and periodic reassessments. a. Identify, implement, monitor and modify interventions (as appropriate) that are consistent with the resident's assessed needs, choices, preferences, goals and current professional standards of practice to maintain acceptable parameters of nutritional status. b. Monitor weight and intake of food and drinks. Review of Resident #81's medical record occurred on all days of survey. Diagnoses included diabetes mellitus Type II, hypertension, and deafness. An admission Mini-Nutritional Assessment (MNA), completed by the dietician on 10/26/23, identified a score of 10, indicating at risk of malnutrition. The current care plan identified, . The resident has unplanned/unexpected weight loss R/T [related to] nausea and poor intakes. Date Initiated: 01/15/2024 . Resident will maintain weight between # [pounds] 155-165 . Resident prefers fluids to help maintain/increase weight. Resident loves drinking juices and boosts. offer food first then fluids if less than 50% intake at meals. The record lacked evidence of implementation of a care plan related to weight loss prior to 01/15/24. Weights obtained since admit included: *10/19/23 194.4 pounds (Lbs) (admission weight) *11/16/23 179.5 Lbs *12/07/23 161.0 Lbs *12/14/23 no weight recorded *12/21/23 159.5 Lbs *12/28/23 159.5 Lbs *01/04/24 158.5 Lbs *01/11/24 no weight recorded *01/19/24 160.8 Lbs *01/25/24 156.0 Lbs *Staff failed to monitor Resident #81's weight for four weeks following admit. Staff failed to monitor the resident's weight weekly after the dietician determined the resident to be at nutritional risk. The weights obtained by staff showed a 14.9 lb weight loss (7.6%) in 30 days (October 19-November 16), and an additional 18.5 lb weight loss (10.3%) over the next three weeks (November 16-December 7). Dietary notes identified the following: *11/20/23 at 12:45 p.m.: . Wt: [weight] 179.5#, down 15# or 8% in the past month = significant loss. This is resident's 2nd weight since admission. Some of the weight loss may be r/t [related to] fluids as resident was started on bumex [a diuretic started on 11/08/23] d/t [due to] poor kidney function. Intake averages 50%. Staff has been giving soup and pizza in place of other items that resident doesn't seem to like. She drinks apple juice at meals, and will eat Boost pudding when offered. Wrote down questions for resident re: [regarding] food. She pointed to snacks on the piece of paper and nodded her head when I mentioned do you like cookies, pudding, yogurt?. Will add fortified to diet order and recommend a high kcal [kilocalorie] snack between meals. Will continue to monitor weekly weights. The record identified staff failed to obtain weekly weights until ordered by the physician on 12/06/23. Review of nursing assessments during this time showed Resident #81 had 1+ edema (slight pitting that disappears rapidly) to 2+ (deeper than 1, disappears in 10-15 seconds) edema in her bilateral lower extremities. *12/04/23 at 12:23 p.m., . Notified of continued poor intake. Resident is only eating 25% meals this past week. No new weight available. Visited with resident's daughters about weight loss and poor appetite. They provided a list of food likes and dislikes. Posted list in kitchen. Resident was given preferred foods at noon meal today, and still refused to eat most of it. She would look at it and shake her head. She is being offered high kcal snack between meals and a high kcal shake at 2 pm. Continue to offer and encourage intake as resident will accept. *12/18/23 at 12:09 p.m.: . Wt: 161#, significant weight loss of 10% in 3 weeks. Resident's appetite remains very poor. She is eating 25% or less at most meals. She is refusing her favorite foods. Staff reports that she has been drinking well. Will add 240 ml [milliliters] Boost [a nutritional supplement] BID [twice a day] between meals. Continue to encourage intake as resident will accept. *01/04/24 at 12:13 p.m.: . Wt: 158#, down 3# in the past month. Weight has stabilized since starting 240 ml Boost BID. Meal intakes remain poor for the most part, eating 25% at meals with an occasional 75-100%. The kitchen offers preferred foods. Resident continues to c/o [complain of] abdominal pain. Unsure if any testing has been done to determine cause. Continue current plan. Observations identified the following: *01/29/24 12:06 p.m.: Resident #81's breakfast tray, containing one piece of toast and 240 ml of supplement, on top of a toaster in the living room area. The tray was untouched, and intake records for the meal identified 0-25% eaten. *01/30/24 at 8:43 a.m.: Resident #81 eating breakfast in the living room area. The tray contained toast and 240 ml of supplement. Resident #81 drank the supplement but did not attempt to eat the toast. A certified nurse aide (CNA) removed the tray and failed to offer Resident #81 other foods/fluids. *01/30/24 at 11:45 a.m.: An unidentified CNA took Resident #81 to the dining room. Observation showed no supplement given during the morning medication pass. *01/30/24 at 11:58 a.m.: Resident #81 sat a table in the dining room. The resident drank 240 ml of supplement and 120 ml of water. At 12:10 p.m., staff brought the resident her meal tray, which consisted of 120 ml juice, pasta, a breadstick, and cheesecake. The resident drank her juice and ate two bites of cheesecake. Throughout the meal, Resident #81 repeatedly lifted her drink glasses to her mouth and tried to take additional drinks from the empty glasses. Observation showed a CNA sat with her at the table, assisting another resident to eat. At 12:35 p.m., the CNA asked the resident if she was ready to go and removed her from the dining room. The CNA and other staff failed to offer Resident #81 additional food/fluids. Intake records for this meal identified staff documented the resident ate 26-50%. Failure of staff to accurately document intakes misrepresents actual intakes consumed by the resident and may result in a delay of additional nutritional interventions necessary to prevent further weight loss. *01/30/24 at 2:08 p.m.: Resident #81 received 120 ml (not 240 ml as ordered) of supplement, of which she drank 100%. During an interview on 01/30/24 at 4:22 p.m., a medication aide (MA) (#3) identified the nurses sign off the supplement in the medication administration record (MAR). The MA identified the supplement comes from the dietary department (around 2:00 p.m.), and the CNAs pass it out. The MA stated the drink Resident #81 had was her afternoon supplement. *01/31/24 at 9:10 a.m.: Resident #81 seated in the living room area with her breakfast tray, consisting of toast and 240 ml supplement. At 9:29 a.m., a staff member attempted to feed the resident a bite of toast, which the resident did not want. The resident consumed 100% of her supplement. The staff member then removed the tray and failed to offer the resident additional food/fluids. *01/31/24 at 11:45 a.m.: Staff brought Resident #81 to the dining room for lunch. Observation showed Resident #81 did not receive a supplement during the morning medication pass (between the breakfast meal and the lunch meal). During an interview on 01/31/24 at 1:38 p.m., a MA (#8) stated she does not give residents supplements, and they come from the dietary department. The MA stated the supplement listed on the MAR for the a.m. medication pass is the one Resident #81 receives at lunch, and the supplement for the p.m. medication pass will be given at supper. The MA stated the dietary department gives the supplements, but the nurses or MAs sign them off in the MAR. The MAR identified, House Supplement two times a day Give 240 ML of Boost BID. Start Date 12/22/2023, scheduled for the a.m. and p.m. medication pass. The MAR identified staff recorded the supplement intakes as check marks (and not the actual amount in milliliters). During an interview on the morning of 02/01/24, an administrative nurse (#4) stated the nurses or MAs should give the supplements as they are listed on the MAR. The facility failed to routinely monitor and assess Resident #81's weight, which resulted in delayed interventions for weight loss and a 33.4 pound weight loss (17%) in less than two months. The facility also failed to accurately document intakes and consistently implement existing weight loss interventions which may have contributed to further weight loss.

Based on record review, review of facility policy, and staff interview, the facility failed to provide appropriate devices to secure a wheelchair and provide sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) during a van transport. Failure to safely transport a wheelchair bound resident resulted in a fall and a fracture for Resident #1 and placed all residents requiring van transportation at risk for falls and injury. Findings include: Review of the facility policy titled Abuse And Neglect occurred on 12/21/22. This policy, revised 10/13/22, stated, .Purpose . The location will have evidence that all alleged or suspected violations are thoroughly investigated. Procedure . 2. The charge nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation. If this is an injury of unknown origin, he or she also will attempt to determine the cause of injury. The facility failed to provide a policy/procedure for securing a wheelchair in a van. Review of Resident #1's medical record occurred on 12/21/22 and showed a diagnoses of displaced supracondylar (the thigh bone, or femur, is broken at the knee) fracture without intercondylar (extending into the knee) extension of lower end of left femur, subsequent encounter for closed fracture with routine healing. The current care plan stated, The resident is at risk for falls R/T [related to] needs assist with all areas of mobility. The resident has dementia E/B [evidenced by] significant memory loss and impaired judgement skills . Resident understands consistent, simple, direct sentences. The progress notes identified the following: * 10/10/22 at 07:55 p.m., . Resident was a near miss incident while out of facility returning from appointment. Driver called into the facility explaining that the resident slipped out of the chair because she put her arms up while in the van [the facility understood the resident slid under the shoulder harness] onto the footrest. The resident was pulled back into the seat 2 person assist and returned to the facility. Resident denied pain and no injuries were noted. Son [name] and administrator made aware. Resident will be encouraged to keep arms down, dycem [an anti-slip pad] applied to seat and no blanket will be provided. * 10/13/22 at 08:00 a.m., . Resident is having increased pain to left knee. Call placed to physician for X-ray order. Order received and resident will go to [name of community] lab via facility van driver for X-ray. POA [power of attorney] made aware. * 10/13/22 at 04:07 p.m., . Per physician resident x-ray showed a fractured left femur. Family is aware . The facility failed to provide van transportation logs that show departures, arrivals, and resident name when requested. The facility provided before and after a trip inspection reports for December 19, 20, and 21, 2022. No further inspection reports were provided. During an interview on 12/21/22 at 12:10 p.m., an administrative staff member (#1) stated the corporate office directed an investigation into the incident be performed. As part of the investigation, the facility re-enacted the scenario on 11/22/22 and discovered the wheelchair harness should go over the shoulders of the resident and through the sides of the wheelchair, rather than around it and the van failed to have the appropriate harness. The facility immediately took the van out of use and ordered a new harness.

Based on record review, review of the facility policy, incident report, and staff interview, the facility failed to follow the physician's order for a regular diet with cut up meat for 1 of 1 resident closed record reviewed (Resident #1). Failure to serve meat ordered by the physician resulted in Resident #1 experiencing a choking episode resulting in death. During an on-site facility incident investigation on [DATE] the survey determined a deficiency at F675. Based on the review of the results of the survey, the State Survey Agency (SSA) team determined an Immediate Jeopardy (IJ) situation existed, but this was not conveyed to the facility until [DATE]. The facility failed to follow the physician's orders for cut up meat when serving shrimp to a resident. The resident experienced a choking episode. Facility staff responded and emergency personal were called to assist. The episode resulted in the resident's death. The potential for harm for other residents could still exist. On [DATE] at 8:14 a.m., the SSA notified the Regional Office (RO) of the IJ and the RO staff agreed. On [DATE] at 8:37 a.m., the SSA management team called the facility and notified the administrator and director of nursing of the IJ and requested a removal plan be submitted to the SSA. The SSA emailed the IJ template to the administrator of the facility. On [DATE] at 5:00 p.m., the SSA received by email and then approved the removal plan from the facility. At 5:12 p.m., the SSA sent an email notification to the facility of the approval and notified the RO. The approval plan contained the following: All Staff meetings were held on [DATE]. Education was provided to all staff on the following: any resident with concerns of swallowing or choking issues need to be reported to the charge nurse immediately, and the following policies were reviewed with all staff members; Care Plan/Rehab Skilled, [MEDICATION(S)] maneuver, and Dining Room Service Rehab/Skilled. All residents care plans were reviewed by [DATE] for Diet Order accuracy, review of resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Updates were made as needed to resident's care plans to ensure all diet orders are being followed as prescribed by physician order. The plan of care was also validated and matched the order sheet used by dietary staff. Education was implemented immediately post event and completed for all dietary staff as of [DATE] on following resident's diet orders and care plan. They were also educated on the following policies: Finger Foods - Food and Nutrition Services, Texture - Modified Diets - Food and Nutrition Services, Diet Orders - Food and Nutrition. All staff were educated on [DATE] on cut meats being no larger than 1.5cm x 1.5cm. Per IDDSI Bite-sized pieces is no bigger than 1.5cm x 1.5cm in size. Director of Nursing or designee will monitor by auditing 5 resident care plans for dietary order accuracy, the orders sheet used by dietary staff, and observing meal pass for those selected residents. Audits will occur weekly for 4 weeks, and then monthly for 2 months. Audits began [DATE]. During the extended survey on [DATE] - 25, 2021, the team verified the implementation of the removal plan and the IJ removal on [DATE]. On [DATE] at 5:20 p.m., the team notified the administrator of the IJ removal. F675 scope/severity of J reduced to a scope/severity of G. Findings include: Review of facility policy titled, DYSPHAGIA (difficulty swallowing) - Food and Nutrition occurred on [DATE]. This policy, revised [DATE], stated, . A resident with dysphagia receives safe and adequate nutrition . based on the resident's ability to chew/swallow and on his or her nutrition needs. Review of Resident #1's medical record occurred on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's physician orders, dated [DATE], stated, . Regular diet . cut meats . Resident #1's current care plan also stated, . Eating: . Diet, Reg [regular] L4 [level 4 per diet manual], . cut meats. A speech therapy discharge summary, dated [DATE], identified . assistance with meal prep (cutting up meats) . set-up assistance. Occasional supervision/supervision from afar . small bites and sips . The progress note identified the following: * [DATE] at 12:07, Late Entry: . 11am resident having brunch in the dinning [sic] room. Approx. [approximately] 11:10am Restorative care . asked writer as she's rush walking towards writer saying: Can you help (Resident #1) she's choking! Looking at resident sitting in wheelchair while on the rush towards nurses station, resident face, especially lips were already purple as she tried to cough the food that was stuck out. CNA [certified nurse's assistant] . came to help. Writer asked CNA . and restorative care . to help resident stand up and writer did [MEDICATION(S)] maneuver but nothing came out. Nurse . came and writer had her take over and do [MEDICATION(S)] maneuver as well but still nothing came out. While nurse . is doing [MEDICATION(S)] on resident, writer called 911 right away to rush to facility. While writer is on the phone with 911, nurse, CNA . and [restorative care] took resident to her room . and laid her on the floor on the back board that nurse . brought. Writer ran to resident's room after calling 911. Nurse . brought oxygen tank and CNA . brought oxygen mask. Put resident initially on 4L [4 liters of oxygen] while resident is on her left side. Writer still attempted back blows [sic] resident's back and also tried doing abdominal thrusts again. Before writer came, nurse . said she also did abdominal thrusts on resident. Resident has some pureed yellow food came out. Approx. 11:20am 911 responders came lead [sic] by . When residents [sic]started working on resident they removed her dentures and suctioned out 4 and a half shrimps from resident. Resident is on a regular diet and kitchen staff does cut up most meats due to her inability to cut them up herself. Shrimp does not require kitchen staff to assist with cutting up. Resident still continued to be unresponsive. While 911 responders were attending to resident, writer went to nurses' station and took POLST [physicians order for life sustaining treatment] copy for responders. They can not do CPR [cardiopulmonary resuscitation] as resident is DNR [do not resuscitate]. Writer also called resident's daughter . and was on her way. Responders' noted time of death at 11:37 am . Review of the incident report dated ,d+[DATE]//21, identified the following: * A cook (#8) stated, . We were serving in the dining room as normal. When I got to her name I put 6 shrimp on her [plate] . We cut her meat so it is easier for her to eat . We do not cut finger food though and that is what the shrimp were. * A dietary aide (#9), stated .We serve [sic] breaded shrimp . to the resident. The resident eats shrimp every time we serve it as it is one of her favorites. When we cleaned up her plate there were only 2 left on her plate, she had eaten everything else on her plate. * Restorative therapy/CNA (#1) stated, . I was in dining room helping [Resident #2] eat when I saw across the table [Resident #1] was choking and as I started to walk over to her I saw something come out of her mouth and then [Resident #1] put it back in her mouth. Then I went over there and and [sic] it looked like she was choking. I then ran to hall and yelled for a nurse. I wheeled resident to nurses station and [nurse] (#5) jumped up and started the [MEDICATION(S)] right away. * A nurse (#4), stated . EMT [emergency medical technician] got 4 ½ shrimp they were about the size of a 50 cent piece [from residents mouth] . EMT did back blows and finger sweeps and requested oxygen at 15 liters. Initially started choking [sic] the dining room at her table. [Nurse #4] states [Resident #1] has choked before but not the extent she needed this kind of medical intervention. * A nurse (#7) stated, . saw the shrimp after [EMS] emergency medical staff had removed from resident's mouth and they were not chewed up at all. During an interview on [DATE] at 12:35 p.m., a dietary manager (#6) stated, I consider shrimp a two bite food. The dietary manager (#6) confirmed the facility did not cut up Resident #1's shrimp on the day of the incident.