Every finding on record at Kemp Care Center

Based on observation, interviews, and record reviews, 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 3 of 3 medication carts (MA Cart 200/400, Nurse Cart 200/400, and Nurse Cart 100/300) and 2 of 5 staff (MA A and RN B) reviewed for pharmacy services. 1. The facility failed to ensure MA A did not sign the controlled substance count sheets for the end of their shift at the beginning of their shift on Cart 200/400 medication aide cart on 08/17/2026 2. The facility failed to ensure RN B did not sign the controlled substance count sheets for the end of his shift at the beginning of his shift on Cart 200/400 Nurse cart on 08/17/2026 3. The facility failed to immediately remove from stock and dispose of expired medication according to procedures for nurse medication cart 100/300 hallway. These failures could place residents at risk for medication diversion, administration of incorrect medication, and not receiving medications as ordered by the physician, and receiving expired medications. An observation on 08/17/2026 at 1:49 PM, revealed MA A was signing on and off at the same time of signing on at shift count, The controlled drugs on hand. for the 200/400 medication cart. An observation on 08/17/2026 at 1:57 PM, revealed 200/400 RN B was signing on and off at the same time of signing on at shift count, The controlled drugs on hand. for the 200/400 Nurse Med Cart. During an interview on 08/17/2026 at 4:00 PM with MA A said she always signed both coming/going slots on the Nurse on and Nurse off at the same time so she would not forget at the end of his shift, She said she thought this was ok to do so she would not forget to sign at the end of her shift,. she knew she would be responsible if something happened during her shift, for possible drug diversion. During an interview on 08/17/2026 at 4:10 PM, RN B said he signed both coming/going slots on the Nurse on and Nurse off at the same time so he would not forget at the end of his shift. He stated he almost always signed the controlled count sheet when receiving control off the count, He stated he knew he should not sign because he was responsible for the cart and the narcotics it contained, and he would be responsible if something happened during his shift. During an interview on 08/17/2026 at 4:14 PM, the ADON said each nurse was to sign the Drug Administration Record Controlled Drug Count Record at the time coming on to their shift and at the time they were going off their shift. The ADON said she was responsible to make sure nurses and MA are signing and counting correctly, this falls on her (ADON). During an interview on 08/17/2026 at 4:20 pm the Administrator and cooperate administrator said, each nurse was to sign the Drug Administration Record Controlled Drug Count Record at the time coming on to their shift and at the time they were going off their shift. Nursing staff must count controlled medication at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the director of Nursing Services. During an interview on 08/17/2026 at 4:20 pm the Administrator and cooperate administrator said, each nurse was to sign the Drug Administration Record Controlled Drug Count Record at the time coming on to their shift and at the time they were going off their shift. Nursing staff must count controlled medication at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the director of Nursing Services. During a record review on 08/19/2026 at 2:00 PM, the sign on/off sheet read, signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication count is in agreement with the quantity stated on the controlled. Record review of the facility's, policy and procedure titled Controlled medication – Administration revised 4/6/26. #8. At each shift change, a physical inventory of all controlled medication is conducted by two licensed nurses and/or one nurse and an MA or equivalent as allowed by your state regulatory agency and is documented on an audit record. #2 Record review of a face sheet dated 08/19/2026 indicated Resident #34 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which, included dementia, psychotic disturbance, mood disturbance, dysphagia (difficulty or trouble swallowing), cognitive communication deficit, malignant neoplasm (abnormal mass of tissue) of the mouth, hyperlipidemia (high blood cholesterol), hyponatremia (low level of sodium (salt) in the blood), hypertension (high blood pressure), chronic obstructive pulmonary disease, gastro-esophageal reflux (GERD), and anxiety. Review of a quarterly MDS assessment dated [DATE] indicated Resident #34 had a Brief Interview for Mental Status (BIMS) score of 00 revealed the resident could not complete MDS/BIMs' assessment. Record review of a face sheet dated 08/19/2026 indicated Resident #56 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which, included dementia, psychotic disturbance, mood disturbance, anxiety, dysphagia (difficulty or trouble swallowing), Alzheimer, respiratory distress syndrome, insomnia (hard to fall or stay asleep), muscle weakness, adult failure to thrive, and bradycardia (abnormally slow heart rate). Review of a quarterly MDS assessment dated [DATE] indicated Resident #56 had a Brief Interview for Mental Status (BIMS) score of 03 indicated the resident was severely impaired. During an observation, interview, and record review on 08/19/2026 at 3:30PM., LVN F's nurse med-cart 100/300 hallway revealed Resident #34's Diazepam A-gel 10 mg/ml syringe ordered to apply 1 ml topically to the inner wrist every 4 hours as needed for anxiety expired on 8/1/2026, and Promethazine cream 25mg/ml syringe ordered to apply 1ml topically to inside of wrist and rub every 4 hours as needed for nausea/vomiting expired on 08/10/2026. Resident #56's Morphine A-suspension 5mg/0.5ml syringe ordered to take 0.5ml by mouth or under the tongue every hour as needed for pain expired 08/3/2026. The medication syringes were removed from the nurses' med-cart, verified as expired by LVN F and the DON. The expired medication syringes were given to the DON to be stored under double lock. LVN F said expired or discontinued medication on the nurse's med-carts were reviewed every week, and she circled the expiration date and forgot to remove the expired medication. She further said expired narcotic medication should be given to the DON and expired non-narcotic disposed of in the pharmacy's destruction bin. LVN F said this practice could lead to medication administration that was no longer safe or effective. During an interview on 08/19/2026 at 3:40 PM, the DON said, she expected the MA and the Nurse staff to immediately remove expired medication from the medication storage room and the medication-carts. She further stated that medications that were expired, contaminated, discontinued, or deteriorated should be disposed of according to procedures for medication disposal. The DON said expired or discontinued medication on nurse's med carts were reviewed every week and expired narcotic medication should be given to the DON to be stored under double lock. The DON said this practice could lead to medication administration that is no longer safe or effective. A record review of the facility's policy dated 2025 title PCU027- Medication Storage in the Facility policy revealed .13. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 3 residents (Resident #59). Resident #59's call light was not within reach when in room on 08/17/2026. The call button was attached to the other side of the resident's privacy curtain. This failure could place residents at risk of not having their needs and preferences met and a decreased quality of life. Finding included: Record review of Resident #59's Face Sheet dated 8/17/2026, reflected a [AGE] year-old female who was originally admitted to the facility at 6/23/2026. Diagnoses included: metabolic encephalopathy (temporary brain confusion caused by a chemical problem in the body), muscle weakness and atrophy(loss of muscle tone), alcoholic cirrhosis of liver, copper deficiency, hypomagnesemia (having too little magnesium in your blood), hypokalemia (having too little potassium in your blood), chronic gout (painful type of arthritis), major depressive disorder, and hypertension (high blood pressure). Record review of Resident #59's admission MDS Assessment, dated 7/27/2026, reflected it a BIMS score of 9 which indicated moderately cognitively intact. She required maximum assistance for eating, hygiene, and upper body dressing. She required total assistance with toileting hygiene and bathing. Record review of Resident #1's Care Plan dated 06/29/2026, reflected, Focus: Resident #59 is at risk for falls. Intervention: Anticipate and meet [Resident #59's] needs. Be sure [Resident #59's] call light is within reach and encourage the resident to use it or assistance as needed. Keep furniture in locked position. Focus: Resident #59 has an ADL Self Care Performance Deficit. Interventions: Encourage [Resident #59] to use bell to call for assistance. In an interview and observation on 8/17/2026 at 11:44 AM, Resident #59 was in her room resting in the geri chair beside bed. The call button was observed hanging on the backside of privacy curtain, out of sight. Resident #59 said she did not know where to find her call light and was unable to locate it when asked. Resident said she would have to wait until staff returned if she needed anything. An observation on 8/17/2026 at 2:26 AM revealed Resident #59 was in room beside the bed in her geri chair with her head turned away from privacy curtain. The call light was hanging on the backside of privacy curtain out of sight and reach of resident. In an interview and observation on 8/17/2026 at 4:00 PM, Resident 59# in geri chair with family at bedside. Call light not within reach family able to locate call light hanging on backside of privacy curtain at that time and placed within reach. Family said call light was not in reach when arriving. In an interview on 8/17/2026 at 4:10 PM, CNA C said she did not know Resident #59's call light was not in her reach. They were to be put back within reach each time staff leave the room after care is given. She said the call light should be accessible to all residents to ensure they can call for assistance if they need it. In an interview on 8/18/2026 at 12:51 PM, Nurse D said call lights should be accessible to residents so they could call for assistance if they needed to. Staff should make sure when they left a room that the call light was within reach, and secured, so residents can call for help as needed. Nurse D said that if they were unable to reach call light, residents could be at risk of falling or other accidents before they received help. In an interview on 10/01/2024 at 3:25 PM, the Administrator stated morning rounds were to be made to monitor this type of concern. He said they looked at things like call lights, room conditions, and residents' needs. He said CNAs were to round during the day to ensure all residents have access to call lights for their safety, and to ensure their needs were met. He said residents were at risk of having to wait for their needs to be met if they were unable to use call light. Record review of the facility's policy titled Resident Rights, not dated, reflected, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.

Based on interview and record review, the facility failed to ensure that a definitive emergency code status was established and supported by a physician's order for 1 of 3 residents reviewed for resident rights (Resident #59).The facility failed to obtain a code status designation on Resident #59's electronic medical profile and failed to secure any active physician orders addressing resuscitation preferences.This failure could place residents at risk of receiving the wrong lifesaving care.Findings included: Record review of Resident #59's Face Sheet dated 8/17/2026, reflected a [AGE] year-old female who was originally admitted to the facility at 6/23/2026. Diagnoses included: metabolic encephalopathy (temporary brain confusion caused by a chemical problem in the body), muscle weakness and atrophy (loss of muscle tone), alcoholic cirrhosis of liver, copper deficiency, hypomagnesemia (having too little magnesium in your blood), hypokalemia (having too little potassium in your blood), chronic gout (painful type of arthritis), major depressive disorder, and hypertension (high blood pressure). Record review of Resident #59's Face Sheet dated 8/17/2026 reflected the section for advanced directives was blank. Record review of Resident #59's admission MDS Assessment, dated 7/27/2026, reflected a BIMS score of 9 which indicated moderately cognitively intact. She required maximum assistance for eating, hygiene, and upper body dressing. She required total assistance with toileting hygiene and bathing. Record review of Resident #59's physician orders, dated 8/17/2026 showed no active order for the resident's code status. In an interview on 8/17/2026 at 4:05 PM, Nurse E said that there was a Code Book behind the nurse's station and that the electronic chart would show at the top of resident's profile. She stated the order should be on the chart for either a full code or DNR for all residents. In an interview 08/18/2026 12:32 PM, the DON said that code status was located on the profile of each resident in the facility's electronic charting system, and they would have a doctor order to match the status. The DON said looking at Resident's #59 chart that both the code status on the face sheet and the physician order were not on electronic chart. She said the resident's code status was reviewed at admission and again with chart audits. She stated the risk of the code status not being in Point Click Care could hinder care given to the residents. Record review of the facility's policy titled Code Status and Advance Directive Acknowledgments, dated 2023, reflected, Every resident will either be a Full Code or DNR (Do Not Resuscitate)

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS assessment was electronically transmitted to the CMS System within 14 days after completion for 2 of 8 residents (Resident #3 and #35) reviewed for resident assessments. The facility failed, on 05/14/2026, to transmit a quarterly assessment to CMS for Resident #3 within 14 days of completion on 04/21/2026 by the MDS Coordinator. The facility failed, on 08/14/2026, to transmit a quarterly assessment to CMS for Resident #35 within 14 days of completion on 07/23/2026 by the MDS Coordinator. These failures could place residents at risk of not having thorough and complete records which could affect their health care.Findings included:Record review of a face sheet dated 08/17/2026 indicated Resident #3 was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia, delusions (a firm fixed belief that is not true and does not change, even when clear and obvious proof show it is false), traumatic subarachnoid hemorrhage (bleeding into the fluid-filled space surrounding the brain caused by a physical head injury), and cerebrovascular disease (a group of medical conditions that affect the blood vessels and blood flow in the brain). Record Review of Resident #3's quarterly MDS assessment dated [DATE] indicated the MDS target date was 04/07/2026 and was signed as completed on 04/21/2026 by the facility RN. The MDS was marked as accepted by CMS on 05/14/2026. The MDS was to be submitted to CMS by 05/11/2026 (within 14 days of completion): 04/21/2026 plus 14 days equals 05/11/2026.Record review of a MDS 3.0 NH CMS Submission Final Validation report printed 08/19/2026 indicated the facility tracking form assessment for Resident #3 was submitted late indicated by: Warning: Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment.Record review of a face sheet dated 08/17/2026 indicated Resident #35 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included nondisplaced fracture of second cervical vertebra, diabetes, high blood pressure, and chronic pain. Record Review of Resident #35's quarterly MDS dated [DATE] indicated the MDS target date was 07/09/2026 and was signed as completed on 07/23/2026 by the facility RN. The MDS was marked as accepted by CMS on 08/14/2026. The MDS was to be submitted to CMS by 08/12/2026 (within 14 days of completion): 07/23/2026 plus 14 days equals 08/12/2026.Record review of a MDS 3.0 NH CMS Submission Final Validation report printed 08/19/2026 indicated the facility tracking form assessment for Resident #35 was submitted late indicated by: Warning: Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment.During an interview on 08/19/2025 at 11:10 AM the MDS Coordinator said sometimes she would be doing a whole lot of things at the same time, and sometimes an MDS would get missed in the batch being made. She said if she failed to check to be sure all of the assessments had been included in the batch, it would fail to be sent to CMS in a timely manner. The MDS Coordinator said it was important to complete and transmit the MDS assessments timely because they affect quality of care measures. She said failure to complete and transmit MDS assessments could result in inaccurate Quality Measures. The MDS Coordinator said the facility used the RAI 3.0 Manual's schedule for completing and transmitting all MDS assessments. During an interview on 08/19/2026 at 11:35 AM, the Administrator said he expected the MDS assessments to be completed and transmitted as scheduled and required by state and federal governing agencies. He said the MDS provided a process for quality of the residents' care. Record review of the CMS's RAI Version 3.0 Manual dated October 2023, Chapter 5: Submission and Correction of Resident Assessments indicated the following: Comprehensive assessments, including the CAA Summary (Section V), must be transmitted within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). Other assessments, like Quarterly and Discharge assessments, must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practices for 2 of 5 residents (Resident #36, Resident #43) reviewed for quality of care. 1. Facility failed to ensure, on 8/17/26 and 8/18/2026, Resident #36's nebulizer mask (is a device used with a nebulizer machine to deliver medication as a fine mist directly into the lungs) and BiPAP machine mask (a small medical device that helps a person breathe by pushing pressurized air into their lungs) was properly covered, stored, and dated. 2. Facility failed to ensure Resident #43's nebulizer setup was properly covered, stored and dated according to infection prevention control practices. These failures could cause residents who require respiratory care to be exposed to potentially increased risk of contamination and respiratory infection and decreased quality of care. Finding included: 1. A record review of Resident #36's face sheet, dated 8/19/26 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (he lungs are permanently too weak to pull enough oxygen into the blood), chronic diastolic heart failure (long-term heart problem where the heart muscle is too stiff to relax and fill with blood properly), obesity, hypotension ( low blood pressure), paroxysmal atrial fibrillation (an irregular, rapid heartbeat that starts suddenly and goes away on its own). A record review of Resident #36's quarterly MDS assessment, dated 7/3/26, revealed Resident #36 had a BIMS score of 13, which indicated he was cognitively intact. A record review of Resident #36's care plan dated 6/14/2026 indicated that Resident #36 had a problem altered respiratory status/difficulty breathing/shortness of breath r/t chronic respiratory failure. Resident #36 was to be given oxygen therapy per physician's orders. A record review of physician orders for Resident #36, dated 7/22/2026, revealed: BIPAP - Settings 18/6 at bedtime Assess O2 Sat. Physician orders dated 8/14/2026, Remove BIPAP upon waking up one time a day and Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG/3ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 8 hours as needed for cough and wheeze. Oxygen LPM: 2-4 Via: NC every shift related to acute on chronic diastolic, heart failure, chronic respiratory failure. During an observation and interview on 8/17/26 at 10:54 a.m., Resident #36's masks her BiPAP and nebulizer were laid over nightstand. The mouthpieces for both the BiPAP and the nebulizer were left out in the open, not covered, and not dated. Bedside table had other items on table including box of tissue paper and bottle of distilled water. The water bottle on the oxygen machine, and it did not have a date written on it to show when it was last changed. Resident #26 said that she was unaware if they put mouth pieces in bags or when the last time they had changed them out. During an observation on 8/18/2026 at 8:28 AM and 8/18/2026 12:20 PM, Resident #36's masks for BiPAP and nebulizer were still laid over nightstand. The mouthpieces for both the BiPap and the nebulizer were still left out in the open, not covered. During an interview on 8/18/2026 at 1:10 p.m., the DON said nursing staff was responsible for ensuring that residents breathing mask were bagged for the nebulizer and BiPAP. She said nurses must make sure the equipment is clean and put into bags right after use, and it should be checked during daily rounds. During an interview on 8/19/2026 at 9:46 AM, LVN D stated nursing staff changed oxygen masks and equipment weekly on Sundays. She noted that either a Certified Nursing Assistant (CNA) or a nurse could bag items like masks and tubing. The LVN also stated that leaving the masks unbagged put residents at risk for germs or infections. 2. A record review of Resident #43's face sheet dated 8/19/2026, indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included altered mental status, muscle weakness, abnormalities of gait and mobility, hyperlipidemia (high level of fats or lipids), depression, hypertension (high blood pressure), gastro- esophageal reflux (GERD: a reflux of stomach acid back flows into the esophagus), and hypokalemia (low potassium). A record review of Resident #43's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicated moderately impaired. Section GG-Functional Abilities: Substantial/maximal assistance. A record review of Resident #43's physician order summary report dated 08/19/2026 indicated Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3 ML) 0.083% (Albuterol sulfate) 1 vial by mask. Written every 8 hours for wheezing and shortness of breath. Active 06/12/2026. During an observation on 8/17/2026 at 10:30AM, an uncovered nebulizer setup was observed on top of Resident #43's bedside table. The nebulizer respiratory equipment connected to 02 tubing was not dated or covered, exposing the respiratory equipment to potential environmental contamination while awaiting the next treatment. During an interview on 8/17/2026 at 10:45AM., CNA-C said the nursing staff changed the respiratory tubing and the nebulizer setup once a week; usually on the night shifts. CNA-C said the nebulizer should remain covered and off the floor to prevent infection. During an interview on 8/17/2026 at 1:00PM., the ADON said nursing staff changed the respiratory tubing and nebulizer setup weekly, usually on night shift and as needed. The ADON said that the nebulizer setup should remain covered and off the floor to prevent infection risk. The ADON said nursing staff should clean, air-dry, and cover the nebulizer setup after each nebulizer treatment. She further said education on respiratory equipment care, infection prevention and control had been completed. Record review of the facility's policy titled Aerosolized Hand-Held Nebulizer, not dated, reflected, Rinse the nebulizer and mouthpiece shake and store in a plastic bag. A record review of the facility's infection control policy and procedure manual policy dated 2019, titled Infection Control Plan: Overview indicated the following: The facility's infection control policies and practices are intended to facilitate, maintain a safe, sanitary, comfortable environment, help prevent, and manage transmission of diseases and infections.AD 03-4.0 Ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed; and uses single-use medication vials and other single use items appropriately. The objectives are to establish guidelines for implementing Isolation Precautions, availability and accessibility of supplies and equipment necessary for Standard and Transmission -Based Precautions.

Based on interview and record review the facility failed to maintain medical records in accordance with the accepted professional standards and practices that are complete and accurately documented for 1 of 1 (Resident #1) residents reviewed for documentation. Resident #1's EMR did not contain complete and accurate documentation that reflected multiple room changes in that there was no documentation in the EMR of all completed room changes between 12/2025 through 08/2026. This failure could result in inaccurate medical records in that the residents or family notification of room changes and reason for room changes were not documented. The findings included: Record review of Resident #1's face sheet dated 08/13/2026 revealed an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a progressive neurological disorder that affects movement), malnutrition, congestive heart failure (a condition where the heart does not pump the blood effectively), dysphagia (difficulty swallowing), hypertension (high blood pressure) and MDD (pervasive sadness that intrudes upon daily life). Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 was usually understood, usually understood what was said to her and had a BIMS score of 4 which indicated severe cognitive impairment. Resident #1 required the use of a wheelchair for mobility, set-up assistance in eating, moderate assistance in toileting, bed mobility, and maximum assistance in transfers. Record review of Resident #1's census record revealed room changes occurred on 08/13/26, 08/07/2026, 07/13/2026, 07/10/2026, 02/15/2026 (two changes occurred), 02/09/2026 and 12/16/2025. Record review of Resident #1's EMR which included progress notes, assessments and miscellaneous documents revealed a Social Worker progress note dated 07/09/2026 at 12:20 p.m., indicated the Social Worker had spoken with Resident #1's family member regarding room change for Resident #1. No other documentation was provided. During an interview on 08/13/2026 at 2:00 p.m., the Social Worker stated she was not aware of the facility guidelines for room changes and that she tried to document them as they occurred but did not always get them documented. The Social Worker stated she was usually responsible for obtaining consent from the resident or the responsible party. During an interview on 08/13/2026 at 3:17 p.m., the DON stated that the facility did not utilize a specific assessment to document room changes for documentation and was not aware that the Social Worker was not documenting the reason for room changes and resident or family notifications. The DON stated that no residents were moved without their consent and to her knowledge, no resident had required a 5-day notice of intent to move because they all agreed to the moves or the move was at their request. During an interview on 08/12/2026 at 4:00 p.m., the Administrator stated that he was aware the company did not utilize room change notices and that he was not aware the room change process was not being documented in the EMR. The Administrator stated it was important for room changes to be documented somewhere in the EMR to ensure accurate records and to ensure that residents' rights were not being violated. The Administrator stated that each department is responsible for the accuracy and completeness of the medical records and he is ultimately responsible for ensuring documentation accurately reflects the resident. During a phone interview on 08/12/2026 at 4:50 p.m., Resident #1's family member stated that the facility kept him informed of the room changes and that some of the moves were at his request and some of the moves were recommended by the facility. Requested policy on documentation or medical records on 08/12/2026 at 4:30 p.m. and was informed by the DON that the facility did not have one.

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for 3 of 3 confidential resident council meetings reviewed (04/18/25, 05/13/25, and 06/10/25) for grievances. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns collected at the resident council meetings on 04/18/25, 05/13/25, and 06/10/25. This failure could place residents at risk of not having their concerns and grievances followed through, and a diminished quality of life. Findings included: Record review of the Resident Advisory Council Minutes for 04/18/25 indicated the call lights were not being answered timely and were worse over the weekend, the residents were not receiving scheduled showers, and they had no towels for bathing, and the residents' beds were not being made timely, and they did not have clean sheets. Record review of the Resident Advisory Council Minutes for 05/13/25 indicated the call lights were not being answered timely, the residents were not always receiving scheduled showers, and the residents' beds were not being made timely. Record review of the Resident Advisory Council Minutes for 06/10/25 indicated the call lights were not being answered timely, the residents were not always receiving scheduled showers, and the residents' beds were not being made timely. Record review of the grievances from April 2025 to June 2025 revealed they did not indicate grievances to address the resident councils' concerns. During a confidential group interview with 9 residents on 06/30/25 starting at 10:08 a.m., the resident group said the facility was shorthanded, people were not getting showers, people's beds were not being made on shower days, people were not getting changed promptly, and call lights were not answered timely. The resident group said that every meeting, they discussed the call lights not being answered timely. The resident group said they had invited some of the department heads, including the DON, to the meetings, and they were aware of the call lights not being answered in a timely manner, showers not being given, and beds not being changed timely. The resident group said they were told they would look into it, or we would investigate it. The resident group said they did not get back with them on a resolution and had not given them an explanation as to why the call lights were not being answered timely as that was their greatest concern. During an interview on 07/01/25 at 5:39 p.m., the Activities Director said, after the resident council meeting, she made three copies of the results of the meeting with the residents' concerns and gave one to the DON, one to the Administrator, and one for the resident council meeting book. The Activities Director said every month, the residents complained about the call lights not being answered, and the Administrator and DON had been told about it. She said she was not aware of what to do about the resident concerns since it had been voiced so many times in the resident council meeting, so she invited the DON to the resident council meeting. She said the residents told the DON about the call lights, showers, and beds not being made in the resident council on 06/10/25. The Activities Director said the DON said she would handle it. The Activities Director said she did not know how to file a grievance. The Activities Director said it was important for the residents' concerns/complaints to be addressed so they felt safe and were taken care of. During an interview on 07/01/25 at 5:38 p.m., the Social Worker said he was responsible for the grievances. The Social Worker said he received the minutes from the resident council, but never really looked at them as far as a grievance. He said he was not aware he needed to fill out the grievance forms from the resident council minutes. He said the Activity Director was supposed to fill out the grievance form and give it to him, and then he would put it into their computer software system. He said they would discuss any grievance in the morning meeting, come up with a resolution (by talking to the resident or investigating the situation), and mark the grievance as completed. The Social Worker said it was important for grievances to be filed so they could be documented and to ensure they were managed appropriately, so it would not happen again. During an interview on 07/02/25 at 10:50 a.m., NA P said the residents complained about their call lights not being answered promptly or not receiving their assigned showers. She said they had a challenging time answering lights and giving showers due to the staffing shortage. She said management was aware of the call lights and showers concerns. During an interview on 07/02/25 at 3:20 p.m., the DON said the Social Worker was responsible for the grievances. She said the Activity Director had given her the resident council minutes, but she had not read thoroughly through them. She said she had been invited to the resident council meeting this month (June 2025) but did not remember anything specific from the meeting about call lights, showers, or beds not being made. She said she had never filled out a grievance form since starting as the DON. She said any concerns voiced at the resident council meeting should have been filed as a grievance. During an interview on 07/02/25 at 3:48 p.m., the Administrator said the Social Worker was responsible for the grievances. She said grievances were talked about in the morning meetings and given to each department head responsible for investigating. She said that after the department head investigated and reached a solution, they resolved the grievance. She said she received the resident council minutes after each meeting from the Activity Director but had not thoroughly reviewed them all. She said she was not aware that a grievance had not been filed from the resident council meetings by the Social Worker. She said if she received a grievance, she would input it into their software system. She said, but she was guilty of sometimes doing verbal communication with issues that were brought to her. She said she now realized the importance of ensuring a grievance had been filed and documented to prove the issues had been investigated and resolved. The Administrator said the resident councils' concerns not being addressed could affect their care, and she expected the residents' needs to be responded to promptly, and if the staff were not answering the call lights, they would not be aware of the residents' needs. Record review of the facility's policy titled, Grievance, revised 11/02/16, indicated, The resident has the right to voice grievances to the facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination. Such grievances include those with respect to care and treatment which have been furnished or have not been furnished, concerns regarding their long-term care facility stay. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievance the resident may have. #2 The grievance officer of this facility is the administrator or their designee, the grievance official will oversee the grievance process, receive and track grievances to their conclusion, lead any necessary investigations by the facility, maintain the confidentiality of all information associated with the grievance, issue written grievance decision to the resident, and coordinate with state and federal agency as necessary. #8 Maintain evidence demonstrating the results of all grievances for no less than three years from the issue of the grievance decision.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 3 of 24 residents (Resident #53, Resident #40 and Resident #29) reviewed for ADL care. 1. The facility failed to ensure Resident #53 was showered or offered a shower as scheduled for June 2025. 2. The facility did not ensure Resident #40 received her shower as scheduled for June 2025. 3. The facility failed to provide Resident #29's showers as scheduled for June 2025. These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: 1. Record review of Resident #53's face sheet, dated 01/29/25, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included Atrial fibrillation, also known as AFib (a heart condition characterized by an irregular and often rapid heartbeat), Dementia (a general term for the loss of thinking, remembering, and reasoning abilities), and Gastroesophageal Reflux Disease, also known as GERD (is a digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn and regurgitation). Record review of Resident #53's quarterly MDS assessment, dated 05/01/25, indicated Resident #53 understood others and was understood by others. Her BIMS score was a 12, which indicated her cognition was moderately impaired. The MDS indicated she required limited assistance for bathing, bed mobility, dressing, and transferring. Record review of the care plan dated 07/24/24 indicated Resident #53 had an ADL self-care performance deficit requiring assistance with bathing. Resident #53 also refused showers at times, revised 06/11/25. The interventions were for staff to assist with bathing, negotiate a time for ADLs, so that the resident participates in the decision-making process. Return at the agreed-upon time, and if the resident resists with ADLs, reassure and return 5-10 minutes later, and try again. Record review of Resident #53’s Documentation Survey Report dated 06/01/25-06/30/25, indicated Resident #53 was to be bathed on the 10 am-6 pm shift, but it did not indicate what days. It appears the days marked for Resident #53 showers were on Monday, Wednesday, and Friday. It showed Resident #53 was bathed on 06/09/25 and 06/11/25 and refused a shower on 06/06/25, 06/16/25, and 06/25/25. During an interview on 07/02/25 at 10:24 p.m., Resident #53 said she was not getting her showers 3 times a week. She said she was lucky to get a shower 1 time a week. She said when she did get a shower, she had to ask several times before she received it. She said she did receive her shower yesterday (07/01/25) after asking several times. During an interview on 07/02/25 at 10:50 a.m., MA O said Resident #53 received her shower late yesterday (07/01/25). She said Resident #53 had to ask the aides several times before they gave it to her. She said she thought Resident #53 was to receive night showers. During an interview on 07/25/25 at 11:00 a.m., NA P said residents did complain about not receiving their baths. She said they were not always able to give the residents showers because of time and all the duties they had to complete. She said she reported to the oncoming shift if a shower was not given. She said they were mostly behind on giving showers because the night aides were not giving their showers. She said she reported to the ADONs and the DON (unknown times) about them not being able to complete their showers, but nothing had changed. 2. Record review of Resident #40’s face sheet, dated 07/01/25, reflected Resident #40 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypercapnia (abnormal high levels of carbon dioxide in the blood). Record review of Resident #40’s quarterly MDS, dated [DATE], reflected Resident #40 made herself understood, and understood others. Resident #40’s BIMS score was 15, which reflected her cognition was intact. Resident #40 required partial/moderate assistance with showering and supervision or touching assistance with toileting, upper/lower body dressing, and putting on/taking off footwear. Resident #20 did not have behaviors or refused care. Record review of Resident #40’s comprehensive care plan revised 02/08/24, reflected Resident #40 had an ADL self-care performance deficit. The care plan interventions included assist with personal hygiene as required: hair, shaving, oral care as needed, and bathing required staff x1 for assistance. Record review of Resident #40’s documentation survey report for the month of June 2025, reflected Resident #40 was scheduled to receive a shower/bed bath on Monday, Wednesday, and Friday between 6:00 AM-2:00 PM. The report reflected Resident #40 did not received a shower/bed bath on 06/02/25, 06/23/25, 06/27/25 and 06/30/25. During an interview on 06/29/25 at 1:26 p.m., Resident #40 was in her bed. Resident #40 stated she had only been receiving her shower once a week and would like to receive them at least 3 times a week. Resident #40 stated, “I feel nasty and dirty” when she did not receive a shower regularly. 3. Record review of Resident #29’s face sheet dated 07/02/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Parkinson’s disease with dyskinesia (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causes unintended or uncontrollable movements with involuntary muscle movements) and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow without chest pain). Record review of Resident #29’s Comprehensive MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #29 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #29 required substantial/maximal assistance with showering/bathing and lower body dressing, and partial/moderate assistance with toileting hygiene, upper body dressing, and personal hygiene. Record review of Resident #29’s care plan last reviewed 04/14/2025 indicated he had an ADL self-care performance deficit to assist him with personal hygiene as required, and he required the assistance of one staff member for bathing. Record review of Resident #29’s Documentation Survey Report for June 2025 indicated he received one bath in the month of June 2025 on 06/17/2025. Record review of Resident #29’s shower sheets for the month of June 2025 indicated he was scheduled to receive showers Tuesday, Thursday, and Friday from 2 PM to 10 PM. The shower sheets indicated he received a shower on 06/22/2025. During an observation and interview on 06/29/2025 at 2:18 PM, Resident #29 said he was not receiving his showers like he wanted. Resident #29 said, “They may give me one on Monday and the next one is Thursday.” Resident #29 said he thought his last shower was Thursday (06/26/2025) or Friday (06/27/2025), but he had no idea of the time, so he was not sure. Resident #29 said he told the staff he needed a bath, and they told him they would get to it, but they did not. Resident #29 said it was normal for them to tell him that. Resident #29 was wearing a white t-shirt with multiple brown stains down the front of it. During an observation and interview on 06/30/2025 at 3:56 PM, Resident #29 had a white t-shirt with multiple brown stains down the front of it. Resident #29 said he thought they had put on a clean shirt on him last night, but he was not sure. Resident #29 said he had not received a shower yet. During an interview on 06/30/2025 at 10:34 PM, LVN E said she worked the night shift from 6 PM-6 AM. LVN E said she thought all the showers were completed prior to the start of her shift since there were more staff available. LVN E said she had not observed any showers being given on her shift. During an interview on 07/01/2025 at 2:23 PM, CNA D said the CNAs turned in the shower sheets to her and she placed them in a file, and then put them in the ADONs’ office. CNA D said the showers were completed on the 6 AM-6 PM shift that there were no showers completed on the 6 PM-6 AM shift. CNA D said she had told the ADONs and the DON that the residents had been missing showers because they were unable to complete all the showers. CNA D said if they were unable to complete a shower/bath during the day shift they left a note for the night shift for them to complete it. CNA D said the residents complained to her that they were not receiving their showers as scheduled. CNA D said if the residents did not receive their showers, it could affect their dignity, and the residents needed to be cleaned. During an interview on 07/01/2025 at 2:49 PM, CNA F said they had missed showers a few times. CNA F said she did not give Resident #29’s showers because he was scheduled to receive his shower on the night shift. CNA F said if the residents did not receive their showers, they could feel neglected and dirty. During an interview on 07/01/2025 at 3:11 PM, ADON H said she had only been the ADON for about a week. ADON H said the staff had not reported to her that they were not able to give all the showers as scheduled. ADON H said the CNAs were supposed to complete shower sheets. ADON H said if the residents did not receive their showers as scheduled, they could have skin breakdown, get infections and odor. ADON H said the residents needed their showers so they could have a general feeling of well-being. During an interview on 07/01/2025 at 3:15 PM, ADON B said she had been the ADON for about a month. ADON B said the staff had not reported to her they were not able to complete all the showers. ADON B said CNA D collected the shower sheets, and the nurses were supposed to review the shower sheets to ensure the residents wee receiving their baths. ADON B said if the residents did not receive their showers, it could affect their skin and self-esteem. During an interview on 07/01/2025 at 3:41 PM, CNA C said she worked the 6 PM-6 AM shift. CNA C said she did not give showers on her shift because she did not have time. CNA C said when she started her shift they had to help with dinner and pick-up trays, then do her rounds, and by the time she finished her rounds it was too late. CNA C said as far as she knew there were showers scheduled but she did not have the time to get to them. CNA C said if the residents did not receive their showers it could result in odors and infections. During an interview on 07/01/2025 at 4:06 PM, LVN G said she worked the 6 PM-6 AM shift. LVN G said the night CNAs were supposed to be giving showers, but by the time they finished dinner and got all the patients changed it was too late to give showers. LVN G said one CNA and two nurses for the building was not enough to provide care for the residents. LVN G said they were supposed to have 3 CNAs at night, but they had a lot of people call in. LVN G said she had talked to CNA D, who scheduled the showers, and told her the CNAs were not able to complete the showers at night. LVN G said the ADONs and DON were aware the residents were not receiving their showers as scheduled. LVN G said she had not been able to find a way to fix the missed showers. LVN G said the residents not getting their baths was neglect. During an interview on 07/02/2025 at 3:05 PM, the DON said the showers were documented on the bathing sheets and the electronic health record. The DON said the CNAs were supposed to turn in the shower sheets to the ADONs for them to review. The DON said the staff had not reported to her that they were unable to complete the showers as scheduled. The DON said if the residents did not receive their showers, it could affect the residents’ personal hygiene. The DON said it was important for the residents to receive their showers to keep them from being sent out to the hospital and to the doctor. During an interview on 07/02/2025 at 3:27 PM, the Administrator said the residents should be placed on the shower schedule, and they should be getting their showers as scheduled. The Administrator said if the resident requested, they could also have a shower in between their scheduled days. The Administrator said nursing was responsible for ensuring the showers were completed. The Administrator said the residents not receiving their showers as scheduled could affect their hygiene. Record review of the facility’s undated policy titled, “Bath, Tub/Shower”, from the Nursing Policy & Procedure manual indicated, “Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation…The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level…The resident will receive assistance with bathing according to their resident centered plan of care…”.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 5 of 24 residents (Residents #1, #10, #29, #48, and #53) and 1 of 1 lunch meal reviewed for palatability. The facility did not provide palatable food served at an appetizing temperature or taste to residents who complained the food was cold and not seasoned. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: Record review of Resident #53's grievance dated 05/08/25, indicated Resident #53 had stated .food was ‘always ice cold'. Record review of the Resident Council Minutes dated 06/10/25 indicated . hall food cold, coffee cold. During an interview on 06/29/25 at 12:36 PM, Resident #1 stated he ate in his room and the food was served lukewarm and needed to be seasoned more. During an interview on 06/29/2025 at 12:44 PM, Resident #48 said the food was cold. During an interview on 06/29/2025 at 1:25 PM, Resident #10 said the food was not good, most of the time it was not seasoned, the meat was too hard, and sometimes the food was cold. During an interview on 06/29/2025 at 2:28 PM, Resident #29 said sometimes the food was cold, but then sometimes the food was too hot to eat. During an observation and interview on 06/30/25 at 1:07 PM, a lunch tray was sampled by the Dietary Manager, the Area Director of Operations and 5 surveyors. The sample tray consisted of meatloaf, red potato wedges, brussels au gratin, roll, and strawberry banana cake. The meatloaf was not sampled as the meat had red tinged areas. The Area Director of Operations said she could see the redness in the meat. She said overall the meal was good. The surveyors observed the redness of the meat, and the potato wedges were lukewarm. During an interview on 07/01/25 at 2:54 PM, the Dietary Manager said there was nothing wrong with the test tray meal. She said the meat loaf was made from ground beef and ground beef was safe to eat at any color if the temperature was correct. She said the potatoes were fine as well and that the Area Director of Operations had agreed there was nothing wrong with the meal. She said she had not received any complaints of cold food. She said residents had even voiced to her that they were happy she was in the kitchen because the food was tasting so much better. During an interview on 07/01/25 at 3:19 PM, the Administrator said if the residents did not like what was being served then they would most likely not eat. She said an alternate meal would have been offered. She said she had received one food complaint that she was aware of for cold food. During an interview on 07/01/25 at 3:25 PM, the Area Director of Operations said she thought the test tray was okay and was aware of the concerns of the surveyors regarding the red meat. She said the ground meat could be served if the temperature was correct, and it had been because the temperature was 197 degrees Fahrenheit. She said there were no concerns from the residents regarding the meal. She said she had not received any food complaints when she had visited the facility. The Area Director of Operations said she visited the facility twice a month and obtained a test tray each time with no issues noted with the meals. Record review of the facility's policy Menu Approval and Honoring Resident Special Requests, and Food Brought to the Facility from Unapproved Sources dated 2012, indicated . 4. Every attempt will be made to honor resident food preferences. The policy did not address the facility providing food that was palatable, attractive, and at a safe and appetizing temperature.

Based on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report was turned into the state survey agency (HHSC) within 5 working days of the reported incident for Resident #1 This failure could place residents at risk for abuse and neglect. Findings Included: Record review of Resident #1's face sheet, dated 06/30/25, indicated he was a [AGE] year-old male, initially admitted to the facility on [DATE] and most recently re-admitted on [DATE]. His diagnoses included heart failure (a condition where the heart can't pump enough blood to meet the body's needs), brief psychotic disorder (mental health condition characterized by the sudden onset of psychotic symptoms, such as delusions, hallucinations, or disorganized speech, that last for at least one day but less than one month, with a full return to the person's previous level of functioning), and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life). Record review of Resident #1's quarterly MDS assessment, dated 04/09/25, indicated he had a BIMS score of 15, which indicated intact cognition. Record review of the facility's provider investigation report for the reported incident for Resident #1, dated 03/15/25, indicated Resident #1 reported that the PASRR representative that took Resident #1 to the store had placed an item on the check out belt and Resident #1 paid for it. The facility notified the local health authority that the representative that he would no longer be allowed in the facility. There were no witnesses to the incident. Ultimately the facility's investigation concluded that the allegation was unconfirmed. The allegation was reported to the state survey agency on 03/11/25. Record review of the TULIP website, accessed on 07/02/25 at 7:58AM, indicated on the page for intake #570206 that a 5-day report or provider investigation report had not been turned into the state survey agency. During an interview on 06/30/25 at 3:00PM, the Area Director of Operations for the facility said they were unable to reach the previous administrator that was responsible for turning in the 5-day report for this intake. She said they were unable to provide proof that the provider investigation report was turned into the state survey agency. On 07/01/25 at 4:25PM, the surveyor attempted to call the phone number that was provided by the facility for the previous administrator. The number was disconnected and no longer in service. Record review of the facility's policy, Abuse/Neglect, last revised 05/09/17, stated: .F. Investigation.3. A report to the appropriate agency will include the following: .The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 24 residents (Resident #1) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #1's discharge MDS assessment dated [DATE] as return not anticipated instead of return anticipated. This failure could place residents at risk for not receiving care and services to meet their needs.Findings included:Record review of Resident #1's face sheet, reflected Resident #1 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included chronic combined heart failure (the heart has a long-term problem with effectively pumping blood, affecting both its ability to contract and relax). Record review of Resident #1's discharge MDS assessment, dated 04/14/25, reflected discharge assessment-return not anticipated. Record review of an admission progress note dated 04/16/25 completed by RN A reflected Resident #1 was readmitted to the facility from the hospital. During an interview on 07/01/25 at 9:10 a.m., the MDS Coordinator stated she was responsible for Resident #1's discharge MDS assessment. The MDS Coordinator stated if a discharge assessment-return not anticipated was completed that reflected the resident was discharged home or to another facility. After reviewing Resident #1's electronic medical records, the MDS Coordinator stated a discharge assessment-return anticipated should have been completed because the return from the hospital on [DATE]. The MDS Coordinator stated a new admission assessment did not have to be done because the MD assessments schedule continued from Resident #1 last MDS assessment. The MDS Coordinator stated she should have modified the assessment to reflect return anticipated. The MDS Coordinator stated it was important to ensure the correct assessment was completed for accuracy. During a telephone interview on 07/0/25 at 9:59 a.m., the Regional Reimbursement Nurse stated the MDS Coordinator should have completed discharge assessment-return anticipated. The Regional Reimbursement Nurse stated the MDS Coordinator should have notified the support line to let them know that she did an incorrect assessment, and they would have reviewed it and gave her the ok to modify. The Regional Reimbursement Nurse stated a new admission assessment did not have to be completed because the resident was not out for more than 30 days. The Regional Reimbursement Nurse stated it was important to ensure the correct assessment was completed for continuity of care. During an interview on 07/02/25 at 2:14 p.m., the Administrator stated she expected the MDS Coordinator to complete the correct assessment when a resident return from a hospital. The Administrator stated it was important the correct assessment was completed to ensure when the resident returned, they would receive the proper plan of care. During an interview on 07/01/25 at 4:39 p.m., the Regional Compliance Nurse stated there was no policy and procedures regarding MDS assessment accuracy. The Regional Compliance Nurse stated the facility followed the RAI manual. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2023, reflected. A1900: admission Date. A1900 (admission Date) . if the resident returns after a discharge return not anticipated or after a gap of more than 30 days outside of the facility, a new episode would begin, and a new admission would be required.

Based on interview and record review the facility failed to coordinate assessments with the PASARR program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents (Resident #32) reviewed for PASARR. The facility failed to ensure a Form 1012 Mental Illness/Dementia Resident Review was completed for Resident #32 after he was initially admitted to the facility on [DATE] to determine if he required further evaluation due to his mental illnesses. This failure could place residents at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.Findings included: Record review of a face sheet dated 07/02/2025 indicated Resident #32 was initially admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and schizoaffective disorder (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #32's Comprehensive MDS assessment dated [DATE] indicated he was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment indicated Resident #32 was usually understood by others and usually understood others. The MDS assessment indicated Resident #32 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #32 had depression, anxiety disorder, and schizophrenia (for example schizoaffective and schizophreniform disorders). The MDS assessment indicated Resident #32 received antipsychotic, antianxiety, and antidepressant medications. Record review of Resident #32's PASRR Level 1 Screening date of screening 10/22/2024, indicated there was evidence that dementia was the primary diagnosis. The PASRR Level 1 Screening indicated there was no evidence or indicator that Resident #32 had a mental illness. Record review of Resident #32's Order Summary Report dated 07/02/2025 indicated he had the following orders: Depakote (medication used to stabilize mood) 250 mg give 1 tablet by mouth three times a day related to schizoaffective disorder with a start date of 10/24/2024. Fluoxetine (medication used to treat depression) 20 mg 1 capsule one time a day for depression with a start date of 10/24/2024. Fluoxetine 40 mg 1 capsule one time a day for depression with a start date of 10/24/2024. Risperidone (medication used to treat mood disorders) 1 mg give 1 tablet by mouth two times a day for anxiety related to schizoaffective disorder with a start date of 10/24/2024. Record review of Resident #32's care plan last reviewed 05/08/2025 indicated he required medications for depression and schizoaffective disorder to administer medications as ordered and monitor/record occurrence of target behavior symptoms. Record review of Resident #32's electronic health record on 07/02/2025 did not indicate a PASRR Evaluation or Form 1012 had been completed. During an interview on 07/02/2025 at 11:55 AM, the MDS Coordinator said she was responsible for the PASRR Level 1 screenings and coordinating PASRR services. The MDS Coordinator said when a resident had a primary diagnosis of dementia, they were unable to indicate on the PASRR Level 1 Screening that the resident had mental illness. The MDS Coordinator said if the resident had a primary diagnosis of dementia, like Resident #32 did, they did not qualify for PASRR services. During an interview on 07/02/2025 at 12:02 PM, the PASRR Manager said if a resident had a primary diagnosis of dementia, they were unable to put yes on the mental illness option on the PASRR Level 1 Screening. The PASRR Manager said because they could not put yes on the mental illness option on the PASRR Level 1 Screening, the facility should complete a Form 1012. The PASRR Manager said the Form 1012 was the facility's justification to show that the resident had a primary diagnosis of dementia. During an interview on 07/02/2025 at 12:12 PM, the MDS Coordinator said she did not know what Form 1012 was that she had not been provided information regarding it. The MDS Coordinator said it was important to ensure the PASRR process was completed properly so the residents who qualified for services received what they needed. During an interview on 07/02/2025 at 2:14 PM, the Regional Reimbursement Nurse said the MDS Coordinator was responsible for PASRR in the facility. The Regional Reimbursement Nurse said she monitored the MDS Coordinator by reviewing the residents' diagnoses and psychiatric notes for new admissions to ensure the PASRR process was being followed. The Regional Reimbursement Nurse said on the PASRR Level 1 Screening when they indicated the resident had a primary diagnosis of dementia, they were unable to indicate the mental illness. The Regional Reimbursement Nurse said Resident #32 did not require a Form 1012. The Regional Reimbursement Nurse said a Form 1012 was only required when it was not clear a resident's primary diagnosis was dementia. The Regional Reimbursement Nurse said it was important for the PASRR process to be followed so if there was mental illness the residents received the services they required. During an interview on 07/02/2025 at 3:29 PM, the Administrator said the MDS Coordinator was responsible for the PASRR process. The Administrator said she expected for the proper PASRR forms to be completed. The Administrator said this was important for the residents to get the programs that were required. Record review of the facility's policy titled, PASRR Nursing Facility Specialized Services Policy and Procedure, revised 03/06/2019, did not address the PASRR Level 1 or completion of Form 1012. Record review of the instructions for the Texas Health and Human Services Form 1012 Mental Illness/Dementia Resident Review indicated, Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I (PL1) Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI). This form is used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis. This form also serves as the NF's documentation for the individual's medical record as to why further evaluation was or was not completed.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 4 (Resident #44) residents reviewed. The facility failed to care plan Resident #44's oxygen (which is vital for the human body as it is used by cells to produce energy) therapy. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #44's face sheet, dated 07/02/25, revealed an [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses to include other nonspecific abnormal finding of lung field ( when an abnormality is detected on diagnostic imaging of the lung, but the specific cause or nature of the abnormality is not yet determined), Neuromuscular dysfunction of the bladder(occur when the nerves controlling the bladder are damaged or don't function properly, leading to issues with storage and/or emptying of urine), stroke and diabetes (high blood sugars). Record review of Resident #44's quarterly MDS assessment, dated 04/22/25, indicated Resident #44 usually understood others and was usually understood by others. Resident #44's BIMS score was 08, which indicated her cognition was moderately impaired. The MDS indicated Resident #44 used oxygen. Record review of Resident #44's care plan, revised date of 04/22/25, did not indicate she had an oxygen care plan. Record review of Resident #44 ‘s physician orders dated 01/06/24 indicated to use oxygen at 2-3 liters per minute via nasal canula every shift for hypoxia (lack of oxygen). During an observation on 06/29/25 at 1:00 p.m., Resident #44 had an oxygen sign outside her door. Resident #44 had oxygen in her room, but it was not on. During an observation and attempted interview on 06/30/25 at 8:33 a.m., Resident #44 was in her bed without any oxygen on. Resident #44 did not answer when asked if she wore oxygen. During an observation and interview on 07/02/25 at 9:33 a.m., the MDS Coordinator looked at Resident 44's care plan and said she did not see the care plan for her oxygen. The MDS Coordinator said she and the IDT worked together to do the care plans, but she was responsible for ensuring the care plans were done. She said it was important to care plan the residents' care so they would receive quality care. During an interview on 07/02/25 at 3:20 p.m., the DON said the MDS Coordinator was responsible for completing the care plans. She said each IDT member was responsible for the acute care plans (IE, the treatment nurse updated wounds, dietary manager updated nutrition, etc.). The DON said she was unaware that Resident #44's oxygen-use was not care planned. She said if Resident #44 had a routine order for oxygen, then she should be wearing her oxygen, and it should be care planned. She said the care plan was generated to guide staff and others in the care the resident should receive. During an interview on 07/02/25 at 3:48 p.m., the Administrator said all disciplines should work together to complete a resident's care plan, but the MDS Coordinator was the overseer. She said care plans were generated to provide each resident with proper care based on their needs and diagnosis. Record review of the facility's policy titled, Comprehensive Care planning, dated 03/2018, indicated Policy Statement: the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's right that includes measurable objective and time frame to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: the services that are to be furnished to obtain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and the right to refuse treatment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her needs, other purposes, and goals, which will address the resident's medical, physical, mental, and psychosocial needs. A comprehensive care plan will be developed within seven days after completion of the comprehensive assessment. The facility will ensure that services are provided, arranged, or delivered by individuals who have the skills, experience, and knowledge to do a particular task or activity. Residents' preferences and goals may change throughout their stay, so the facility should have ongoing discussions to ensure that changes are reflected in the comprehensive care plan.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #51) of 1 resident reviewed for enteral nutrition. The facility failed to follow physician orders for Resident #51's enteral feeding tube to be administered at 53 ml/hr. This failure could place residents who had gastrostomy tube at risk for fluid overload.Findings included: Record review of Resident #51's face sheet, dated 07/01/25, reflected Resident #51 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition. Record review of Resident #51's quarterly MDS assessment, dated 04/15/25, reflected Resident #51 made herself understood, and usually understood others. Resident #51's BIMS score was 13, which reflected her cognition was intact. Resident #51 had a feeding tube that she received 51% total calories through the feeding tube. Record review of Resident #51's comprehensive care plan revised on 12/31/24 reflected Resident #51 required a feeding tube for nutrition. The care plan interventions included: check for tube placement and gastric contents/residual volume per facility protocol and record. Record review of Resident #51's physician order summary report, dated 07/01/25 reflected an active physician order for enteral feeding at bedtime start continuous: Isosource 1.5 calorie (formula): rate 53 ml/hr with a start date 02/06/25. Record review of a progress note dated 06/30/25 completed by LVN K reflected Resident #51 had significant residual (something that remains or was left behind after a process, treatment, or event has occurred) noted. Nurse Practitioner notified, new order hold feeding for 2 hrs. and recheck residual. During an observation on 06/29/25 at 1:42 p.m., Resident #51 was lying in bed. The feeding tube machine reflected, Isosource 1.5 calorie at a continuous rate of 55 ml/hr. During an observation and interview on 06/30/25 at 09:29 AM, LVN K checked Resident #51's room to administer her routine morning medications via her peg tube. LVN K stopped the feeding pump, checked for peg tube placement and residual. Resident #51 had 60 mL of residual. After LVN K administered Resident #51's medication she said she was not restarting the feeding because Resident #51 had quite a bit of residual and had to notify the physician. During an observation on 06/30/25 at 2:50 p.m., Resident #51 was lying in bed. The feeding tube machine reflected, Isosource 1.5 calorie at a continuous rate of 55 ml/hr. During an observation and interview on 06/30/25 at 2:52 p.m., after reviewing Resident #51's electronic medical records, LVN K stated Resident #51 tube feeding formula rate should be 53 ml/hr. LVN K observed the rate with the state surveyor at 55 ml/hr. LVN K stated the charge nurses were responsible for verifying each order, every shift, every time the resident's feeding was administered. LVN K stated receiving 55 ml/hr instead of 53 ml/hr of feeding formula would result in overload. During an interview on 07/02/25 at 10:09 a.m., the DON stated she expected the nurses to follow the physician order. The DON stated her and the ADONs were responsible for monitoring accuracy by daily champion rounds and random checks throughout the day. The DON stated, It was missed. The DON stated it was important for the resident to receive the correct rate for their safety. During an interview on 07/02/25 at 2:14 p.m., the Administrator stated she expected the nurses to ensure the correct rate was set per the physician order. The Administrator stated the DON/ADONs were responsible for monitoring. The Administrator stated it was important for the resident to receive the correct rate to prevent overload. Record review of the undated facility's policy titled Enteral Nutrition reflected. We will provide nutritionally complete enteral or parenteral feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth. 1. The Nursing Services Department is responsible for all feeding equipment and the administration of tube feedings.

Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 3 residents (Resident #48) reviewed for respiratory care. The facility failed to ensure Resident #48's CPAP (a device that keeps breathing airways open while sleeping) mask was stored properly. This failure could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.Findings included: Record review of a face sheet dated 07/02/2025 indicated Resident #48 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed air flow in the lungs). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #48 understood others and was understood by others. The MDS assessment indicated Resident #48 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #48 was dependent on staff for eating, oral hygiene, dressing, and required partial/moderate assistance with personal hygiene and eating. The MDS assessment did not address the use of a CPAP. Record review of Resident #48's Order Summary Report dated 07/02/2025 indicated she had an order for may use CPAP at bedtime with a start date of 05/29/2025. Record review of Resident #48's care plan last reviewed 05/28/2025 indicated she required the use of a CPAP, and she would use the device as ordered. During an observation and interview on 06/29/2025 at 12:44 PM, Resident #48's CPAP mask was on top of a bubble gum container that was on top of her nightstand, and it was not in a bag, it was exposed. Resident #48 said the staff usually kept it that way and did not store it in a bag. Resident #48 said the staff had to assist her with putting it on and taking it off because she was unable to do it on her own. Resident #48 said she could not reach her CPAP mask due to her limited mobility. During an interview on 07/02/2025 at 2:46 PM, ADON B said the CPAP masks should be placed in a bag when not in use. ADON B said she conducted rounds daily in the mornings to ensure they were stored properly. ADON B said the night nurses were responsible for ensuring the CPAP masks were stored in a bag. ADON B said it was important for the CPAP masks to be stored in a bag when not in use for them to be kept sanitary. During an interview on 07/02/2025 at 2:59 PM, the DON said the CPAP masks should be stored in a bag when not in use. The DON said ultimately, she was responsible for ensuring they were stored properly. The DON said they conducted champion rounds during the week and the RN supervisor on the weekend ensured the masks and cannulas were stored in a bag. The DON said the CPAP mask not being stored properly could result in it not being clean and could cause an infection. During an interview on 07/02/2025 at 3:24 PM, the Administrator said the CPAP masks should be stored in a bag when not in use. The Administrator said the nurses were responsible for ensuring this occurred. The Administrator said it was important for them to be stored in a bag for infections reasons and to keep them clean. During an interview on 07/02/2025 at 3:39 PM, RN A said the CPAP masks should be stored in a bag when not in use. RN A said she did not know why Resident #48's CPAP mask was not stored in a bag. RN A said she tried to check in the mornings when she went into the residents' rooms to ensure the CPAP masks and nasal cannulas were stored properly. RN A said it was important for the CPAP masks to be stored in a bag to protect them from dust and germs. Record review of the facility's policy titled, Oxygen Administration, revised March 21, 2023, did not address the storage of CPAP masks.

Based on observation, interviews, and record reviews, 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 1 of 5 residents (Resident #6) reviewed for pharmacy services. The facility failed to ensure ADON H administered Resident #6's Magdelay (magnesium chloride, combination medication used as a supplement for minerals lacking in diet) as ordered on 06/30/25. This failure could place the residents at risk of not receiving the intended therapeutic benefits of prescribed medications.Findings included: Record review of Resident #6's face sheet dated 07/01/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), essential hypertension (high blood pressure), muscle weakness, and osteoporosis (disease that weakens the bones and increases the risk of fractures). Record review of Resident #6's quarterly MDS assessment dated [DATE], indicated she was understood and understood others. Resident #6 had a BIMS score of 14, which indicated her cognition was intact. Record review of Resident #6's comprehensive care plan revised 01/16/24, indicated she had impaired cognitive function/dementia or impaired thought processes. The care plan interventions indicated to administer medications as ordered. Record review of Resident #6's order summary report dated 07/01/25, indicated she had an order for MagDelay 64mg give one tablet one time a day for supplement with an order started date of 06/01/25. During an observation on 06/30/25 at 08:45 AM, ADON H prepared Resident #6's routine morning medications. ADON H obtained one tablet of sloMg and placed it in the medicine cup. The bottle of sloMg indicated it contained the following ingredients: magnesium 143mg, calcium 238mg, and chloride 416mg. ADON H then administered Resident #6 her medications. Resident #6 took all medications including the sloMg tablet. Record review of Resident #6's medication administration record dated 06/01/25-06/30/25, indicated she had received one tablet of Magdelay 64mg on 06/30/25 in the morning and had been administered by ADON H. Record review of the website on 07/01/25, https://hargravesotc.com/products/magdelay-64-mg-delayed-release-60-tablets-by-major?variant=32392354562131, indicated the active ingredients for Magdelay included: calcium 212mg, magnesium 128mg, and chloride 375mg. During an interview on 07/01/25 at 2:32 PM, ADON H reviewed the bottle of sloMg she administered and said it was not the correct dosage, and she should have not administered the medication to Resident #6 until she had clarified the order with the physician. ADON H said she had given the medication because it had handwritten on the top of the bottle magnesium delay. She said she had only administered one tablet although the bottle had indicated a dose was 2 tablets because she assumed she had calculated the magnesium correctly and obviously she did not. She said she was responsible for ensuring the medications were being administered as ordered. ADON H said not administering the correct medication was a medication error and Resident #6 was at risk for receiving more than the prescribed dose which could cause cardiac related adverse reactions. During an interview on 07/01/25 at 3:16 PM, the DON said she expected medications to be administered as ordered. The DON said the nurse was responsible for clarifying the order with the physician. The DON said not giving the correct dose of medication was a medication error and the resident could have ill effects depending on their diagnoses. During an interview on 07/01/25 at 3:19 PM, the Administrator said she expected medications to be administered following the medication rights. She said ADON H should have had called the physician to get clarification if the medication could be administered. She said failure to administer medications as ordered could cause the resident not to get the therapeutic level of the ordered supplement. Record review of the facility's undated policy Medication Administration and General Guidelines indicated. Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized themselves with the medication.

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 24 residents (Resident #20) reviewed for medications at their bedside. The facility did not ensure Resident #20's Ayr Nasal Solution (nasal spray), and biotene dry mouth moisturizing spray were not left on his bedside table. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.Findings included: Record review of Resident #20's face sheet, dated 07/01/25, reflected Resident #20 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included diastolic (congestive) heart failure (occurs when the heart's lower left chamber becomes stiff and cannot relax and fill with blood properly between beats). Record review of Resident #20's quarterly MDS, dated [DATE], reflected Resident #20 sometimes made himself understood and usually understood others. Resident #20's BIMS score was 14, which reflected his cognition was intact. Record review of Resident #20's comprehensive care plan revised on 11/11/24 reflected discharge from the facility was not feasible as evidenced by resident unable to safely self-medicate and required 24 hr. nursing care. The care plan interventions included respect resident's right to view nursing facility as his home. Record review of Resident #20's order summary report dated 06/01/25 reflected an active physician order for Ayr Nasal Solution: 2 sprays in both nostrils every 4 hours as needed for nasal irritation with a start date 06/29/25. Record review of Resident #20's order summary report dated 06/01/25 reflected an active physician order for biotene dry mouth moisturizing spray: 1 spray by mouth every 4 hours as needed for dry mouth with a start date 06/29/25. During an observation and attempted interview on 06/29/25 at 1:58 p.m., A bottle of Ayr Nasal Solution (nasal spray) and biotene dry mouth moisturizing Spray were observed on Resident#20's bedside table. Resident #20 had a communication problem related to unclear speech. During an observation and interview on 06/29/25 at 2:00 p.m., the DON was coming out of the room next door to Resident #20 when the state surveyor asked her if anyone on the hall was able to self-medicate. The DON stated there was no one in the building able to self-medicate. The state surveyor asked the DON if the nasal spray and the mouth moisturizing spray should be on Resident #20's bedside table. The DON removed the medication from the table and told Resident #20 the medication should be stored in the nurse's cart. During an interview on 06/29/25 at 2:03 p.m., ADON H stated Resident #20 had not been evaluated for self-administration of medications. ADON H stated if a resident was able to self-administer, he/she must be assessed for competence. ADON H stated once the resident was safe to self-medicate an order must be obtained. ADON H stated she did not see the medication on his bedside table when she went into his room. ADON H stated, he has so much stuff on that table. ADON H stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 07/02/25 at 10:09 a.m., the DON stated she expected that if Resident #20 was able to self-administer that the resident be assessed, obtain an order for the resident to self-administer and store the medications on the nurse's cart. The DON stated all staff should be ensuring medications were not left at bedside. The DON stated she was responsible for monitoring medications at bedside by daily champion rounds. The DON stated she was not aware if a round was made that morning prior to surveyor intervention. The DON stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 07/02/25 at 2:14 p.m., the Administrator stated medications should be locked/secured in the nurse's cart and administered by the nurse or MA. The Administrator stated the DON was responsible for monitoring and overseeing medication storage by daily rounds. The Administrator stated it was important to ensure medications were not left at bedside for resident safety. Record review of the undated facility's policy titled Medication Storage in the Facility reflected. 2. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs for 1 of 2 residents (Resident #19) reviewed for dietary needs and preferences. The facility failed to ensure Resident #19 received small, frequent meals as recommended by her physician. This failure placed residents at risk for altered nutritional status and decreased quality of life. Findings included: Record review of Resident #19's face sheet dated 07/02/2025 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus with other circulatory complications (insulin resistance leading to high blood sugars resulting in complications with circulation), gastro-esophageal reflux disease without esophagitis (a long-term condition in which acid from the stomach comes up into the esophagus without inflammation of the esophagus), and irritable bowel syndrome (condition that affects the digestive system and can cause abdominal pain, cramping, bloating, gas, constipation, and diarrhea). Record review of Resident #19's Quarterly MDS assessment dated [DATE] indicated she understood others and was understood by others. The MDS assessment indicated Resident #19 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #19 was independent for eating. The MDS assessment did not indicate Resident #19 required a therapeutic diet. Record review of Resident #19's Order Summary Report dated 07/01/2025 indicated she had an order for a regular diet with regular texture and consistency with a start date of 11/19/2024. Record review of Resident #19's care plan last reviewed 04/14/2025 indicated she had a potential nutritional problem related to diabetes mellitus to provide and serve diet as ordered. Record review of Resident #19's Physician's Orders in her After Visit Summary from the gastroenterology lab (specialized area where procedures and tests related to the digestive system are performed) dated 05/29/2025 indicated, gastroparesis (condition where the stomach empties its contents too slowly) with solid food in stomach likely diabetic gastroparesis (condition in people with diabetes that causes delayed emptying of the stomach). should be on small frequent meals 4-5 times daily. Record review of Resident #19's electronic health record indicated the last Dietary Profile completed was on 04/16/2025, and it did not address Resident #19's requirement of small frequent meals. The Dietary Profile was signed completed by the Dietary Manager on 04/16/2025. During an interview on 06/29/2025 at 2:30 PM, Resident #19 said she had diabetic gastroparesis and was told by the doctor she was supposed to have little meals. Resident #19 said she was supposed to eat every 2 hours, and the facility could not accommodate that for her. Resident #19 said she did the best she could to eat small meals by saving food from the meals she was served to eat throughout the day. Resident #19 said she talked to the kitchen manager, and they flat out say they cannot do it. Resident #19 said the kitchen manager told her everybody received the same diet. During an interview on 07/01/2025 at 4:47 PM, the Dietary Manager said if a resident required a special diet the nursing staff notified dietary, and they tried to accommodate the diet. The Dietary Manager said a diet order should be completed and given to the kitchen. The Dietary Manager said she tried to visit the residents monthly and completed dietary profiles to get the residents' dietary preferences. The Dietary Manager said she was not aware Resident #19 required small, frequent meals, and she was not provided a diet order. The Dietary Manager said she tried to visit with Resident #19 every couple of weeks, and Resident #19 had not informed her she wanted small, frequent meals. The Dietary Manager said it was important to accommodate the residents' dietary needs and preferences for their dignity and because they should have as much control as possible over their meals. During an interview on 07/02/2025 at 2:49 PM, ADON B said Resident #19 had gastroparesis, and was instructed to eat small meals. ADON B said when a resident went to the doctor the nurses should review the orders upon the residents return to the facility. ADON B said she thought she may have been the charge nurse the day Resident #19 returned with the order for the small meals, but she did not remember. ADON B said she did not complete a dietary communication sheet, and it should have been completed. ADON B said she did not put an order in because she guessed in her mind she did not because Resident #19 controlled her meals. ADON B said if the residents' dietary needs and preferences were not followed it could cause adverse reactions and have a bad outcome. During an interview on 07/02/2025 at 3:02 PM, the DON said the nurses were responsible for reviewing the physician's orders when the residents returned from a doctor's appointment. The DON said the ADONs and herself reviewed the orders after the nurses did. The DON said she was aware Resident #19 required small, frequent meals. The DON said she had communicated it to the Dietary Manager in one of the morning meetings. The DON said if there was a diet order change a communication form should be completed and given to dietary. The DON said since she communicated it to the Dietary Manager in the morning meeting, she did not complete a communication form. The DON said if Resident #19's dietary needs were not followed as recommended by the physician she could end up having to go back to the doctor. During an interview on 07/02/2025 at 3:25 PM, the Administrator said if Resident #19 required frequent meals they should be able to provide her snacks or they could store food for her, and she could get it or request it later. The Administrator said when they received information from the physician it should be communicated from the DON/ADON to dietary. The Administrator said if the residents' dietary needs and preferences were not followed, they would not get the proper meals they needed. Record review of the facility's policy titled, Menu Approval and Honoring Resident Special Requests, And Food Brought to the Facility From Unapproved Sources from the Dietary Services Policy & Procedure Manual 2012, indicated, .Every attempt will be made to honor resident food preferences. If a resident wishes to eat at non-traditional times or outside of scheduled meal service times, the resident preferences will be honored as much as possible. The facility plan for meeting these requests will be documented in the resident's written care plan. If a resident has requested in advance to eat at non-traditional times, the foods served on the menu can be stored and reheated at the appropriate time, or shelf-stable/refrigerated foods that can be prepared without access to the facility kitchen can be kept on hand for these requests.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure:1. The ham was discarded after the use by date of 06/26/25.2. The potatoes were labeled and dated. These failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation of the kitchen on 06/29/25 beginning at 11:20 AM, the following was revealed in the fridge: Ham had a use by date of 06/26/25. Potatoes were found in a container with no label or date. During an interview on 07/01/25 at 2:54 PM, the Dietary Manager said the ham was unfortunately 1 day out of date. She said the potatoes had just been pulled from the freezer, were labeled, and dated but the label had gotten soggy from the ice. She said a new label should have been placed. The Dietary Manager said the ham should have been pulled on the day it expired and thrown away. She said the fridges were checked daily for expired food and she was unsure how it was missed. The Dietary Manager said the cooks and herself were responsible for ensuring the food was labeled correctly, and expired food was removed. She said failure to remove the expired food items could cause the residents to get sick. During an interview on 07/01/25 at 2:58 PM, Dietary [NAME] M said he checked the fridges daily for expired food. He said the potatoes should have been labeled and dated when they were prepared, and the ham should have been removed the day it expired. Dietary [NAME] M said failure to remove the expired food or not labeling/dating correctly could place a resident at risk for receiving expired food and cause them to get sick. He said the kitchen staff was responsible for ensuring the food was labeled/dated correctly and expired food was removed. During an interview on 07/01/25 at 3:19 PM, the Administrator said she expected all food items to be labeled and dated accordingly and discarded upon the expiration date. The Administrator said the Dietary Manager was responsible for overseeing it was being completed. She said depending on the food itself expired food could case GI discomfort and upset for the residents if used. Record review of the facility's policy Food Storage and Supplies dated 2012 indicated. All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.Perishable items that are refrigerated are dated once opened and used within 7 days.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #44) reviewed for infection control. The facility failed to ensure CNA N performed hand hygiene while providing incontinent care for Resident #44 on 06/29/25. This failure could place any resident at the facility at risk for cross-contamination and the spread of infection.Finding included: Record review of Resident #44's face sheet, dated 07/02/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include Neuromuscular dysfunction of the bladder (occurs when the nerves controlling the bladder are damaged or don't function properly, leading to issues with storage and/or emptying of urine), stroke and diabetes (high blood sugars). Record review of Resident #44's quarterly MDS assessment, dated 04/22/25, indicated Resident #44 usually understood and was usually understood by others. Resident #44's BIMS score was 08, which indicated her cognition was moderately impaired. The MDS indicated Resident #44 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS did not indicate she was frequently incontinent of bladder. Record review of Resident #44's comprehensive care plan, revised on 07/27/23, indicated that Resident #44 had an ADL Self Care Performance Deficit. The care plan interventions were for 2 staff to provide toileting. During an observation on 06/29/25 at 1:00 p.m., CNA N provided incontinent care of bowel and bladder for Resident #44. She wiped her front area and then her backside without changing her gloves or performing hand hygiene. She then grabbed a clean brief, applied barrier cream, changed her linen, and then applied her gown, while using the same dirty gloves. CNA N then removed her gloves, gathered her equipment, left the room, and then washed her hands. During an interview on 06/29/25 at 3:02 p.m., CNA N said she did not realize she did not perform hand hygiene or change her gloves after wiping Resident #44, then touching the clean brief, linen, and her gown with dirty gloves. She said she knew that without hand hygiene or removing dirty gloves, she could cause cross-contamination and infection. During an interview on 07/02/25 at 3:20 p.m., the DON said she expected the CNAs to perform incontinent care correctly. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes. The DON said they went over incontinence care and hand washing at least annually. She said she oversaw the infection control process. She said staff should change gloves and practice hand hygiene to prevent infection and cross-contamination. During an interview on 07/02/25 at 3:48 p.m., the Administrator said she expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the DON was responsible for ensuring staff were trained on incontinent care and infection control. She said improper hand hygiene could place residents at risk for cross-contamination. Record review of the facility's policy titled Hand Hygiene, undated, indicated, You may use alcohol-based hand cleaner or soap and water for the following: when hands are visibly soiled, after contact with a residents mucous membrane and body fluids or excretions, after handling soiled or used linens, before and after assisting a resident with personal care, and before and after assisting a resident with toileting. Record review of the facility's policy titled Infection Control, revised 03/23, indicated, The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by acceptable professional practice.

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 5 of 6 residents (Resident #14, Resident #36, Resident #47, Resident #115, and Resident #218) reviewed for pressure ulcers. 1. The facility failed to ensure weekly ulcer assessments were performed and measurements were obtained for Resident #47's left outer ankle stage 4 pressure injury, Resident #218's pressure injuries to her buttocks, fluid filled blister to great toe, ulcer to right foot, Resident #14's pressure injury to his left buttock, Resident #115's stage 3 pressure injury to his left buttock. 2. The facility failed to ensure wound care treatments were performed as ordered for Resident #36, Resident #115, and Resident #218. 3. The facility failed to ensure Resident #14's and Resident #115's treatment orders indicated the correct location of their pressure injuries for wound treatment. 4. The facility failed to ensure the treatment nurse completed the ulcer assessment weekly for Resident #47 and her wound increased in size. 5. The facility failed to have a system in place to ensure skin assessments and treatments were completed as ordered. 6. The facility failed to ensure skin assessments were performed accurately. 7. The facility failed to prevent further worsening of Resident #36's moisture associated skin damage to bilateral buttocks. 8. The facility failed to follow their Skin Integrity Management policy. 9. The DON failed to provide oversight for wound care management and assessments. An Immediate Jeopardy (IJ) situation was identified on 04/30/24 at 3:50 PM. The IJ template was provided to the facility on [DATE] at 4:28 PM. While the IJ was removed on 05/01/24 at 5:47 PM, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness, paralysis of left side of the body after a stroke). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #14 was sometimes understood by others, and he was usually able to understand others. The MDS assessment indicated Resident #14 had a BIMS score of 8, which indicated his cognition was moderately impaired. The MDS assessment did not indicate any behaviors or rejection of care. The MDS assessment indicated Resident #14 was dependent for toileting hygiene, showering/bathing self and required partial/moderate assistance with personal hygiene. The MDS assessment indicated Resident #14 was at risk for pressure ulcers/injuries. The MDS assessment indicated Resident #14 did not have any pressure ulcers/injuries. Record review of the care plan last reviewed 03/22/24 indicated Resident #14 had a potential impairment to skin integrity related to fragile skin. Interventions included to follow facility protocols for treatment of injury and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Resident #14's care plan did not indicate he had any pressure injuries. Record review of Resident #14's Order Summary Report dated 04/29/24 indicated: Buttock: Cleanse with wound cleanser/normal saline, pat dry; apply anasept (gel used for wounds) apply dry dressing; daily and as needed order date 04/25/24. The order failed to include which buttock to perform the wound care on. Wound consult related to opening on buttock order date 04/25/24. The order failed to indicate which buttock there was an opening to. Record review of Resident #14's Weekly Skin assessment dated [DATE] completed by the Treatment Nurse indicated yes to moisture associated skin damage. The assessment indicated to note the location, measurements of any moisture associated skin damage, right and left buttock was the response with no measurements. The assessment indicated Resident #14 had no pressure, venous, arterial, or diabetic ulcers. Record review of Resident #14's electronic health record on 04/30/24 did not indicate any Weekly Ulcer Assessments had been completed. During an observation and interview with the Treatment Nurse on 04/30/24 at 12:20 PM, Resident #14 had an open area to his left buttock. The Treatment Nurse obtained measurements and said they were 3 cm x 2 cm x 0.1 cm. Record review of a progress note dated 04/30/24 at 3:56 PM completed by the Treatment Nurse indicated, Resident #14 was seen by the wound care doctor on 04/30/24 via tele med (use of technology to communicate with the doctor without them being in the room) and had a stage 3 to the right buttock with measurements of 3.0 cm x 1.5 cm x 0.1 cm to continue with the current treatment. 2. Record review of Resident #218's face sheet dated 04/30/2024, indicated a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses which included diabetes (a group of diseases that affect how the body uses blood sugar), hypertension (high blood pressure), congestive heart failure (the heart can't pump blood well enough to supply the body, unspecified wound to abdominal wall of right lower quadrant, and cellulitis (serious bacterial infection of the skin) right lower limb. Record review of Resident #218's comprehensive care plan dated 04/24/2024 and revised on 04/29/2024, indicated Resident #218 had a surgical site to groin, and right calf. The care plan interventions included wound vac (wound vacuum device that removes pressure over the area of the wound) to right lower extremity. The care plan also indicated the Resident #218 had the potential/actual impairment to skin integrity related to fragile skin with interventions to follow facility protocols for treatment of injury. Record review of Resident #218's initial skin assessment dated [DATE] and completed by the Treatment Nurse indicated Resident #218 had a skin tear to left and right buttock (no measurements were indicated for the skin tears) and a surgical incision to right leg with a wound vac placed. Record review of Resident #218's Order Summary Report dated 04/28/2024, indicated she had the following orders: *Right leg: Cleanse wound and wet to moist until vac available as needed for wound healing with a start date of 04/24/2024. *Right leg: Cleanse wound with normal saline/wound cleanser, pat dry, apply green foam, negative pressure (-125mmHg) continuous wound therapy, apply three times a week and as needed on Monday, Wednesday, and Friday for wound healing with a start date of 04/25/2024. *Right side of groin: Cleanse with normal saline/wound cleanser, apply wet to dry dressing to area, apply bordered dressing change as needed if soiled for wound healing with a start date of 04/25/2024. *Right side of groin: Cleanse with normal saline/wound cleanser, apply wet to dry dressing to area, apply bordered dressing change one time a day for wound healing with a start date of 04/25/2024. Resident #218's Order Summary Report did not reveal orders for the skin tears to her buttocks. Record review of Resident #218's electronic health record on 04/30/24 did not indicate any weekly ulcer assessments were completed. During an observation and interview on 04/28/24 at 11:23 AM, Resident #218 said she had admitted to the facility from the hospital last week. Resident #218 said the Treatment Nurse had not been changing her dressings as scheduled. Resident #218 said her wound vac dressing should be changed on Monday, Wednesday, and Friday. Resident #218 said it was not changed on Friday (04/26/24), and she had asked the Treatment Nurse to change it yesterday (04/27/24) and she had not. The dressing on the wound vac was not dated. During an observation and interview with the Treatment Nurse on 04/29/24 at 3:13 PM, Resident #218 had an open area to her left buttock. The Treatment Nurse obtained measurements and they were 1 cm x 2 cm x 0.5 cm. Resident #218 had multiple shear areas (shallow open areas to the skin) to her right buttocks. The areas were approximately less than 0.3 cm x0.3 cm x 0.1cm. Resident #218's right great toe was purple, and the bottom of the right great toe had a fluid-filled blister to it. Resident #218 had a black circular area to the side of her foot that had no dressing to it. It measured approximately 1 cm x 1cm with an undetermined depth, and the middle was concave and dark black. Resident #218 said she was not aware her right great toe was purple. Resident #218 said the circular area to the side of her right foot had drainage at times and she had it since she admitted to the facility. The Treatment Nurse said she had only been employed at the facility for a month and a half. The Treatment Nurse said she had only been the Treatment Nurse for 2 weeks because she had been having to work the floor due to staffing issues. The Treatment Nurse said LVN M was supposed to change Resident #218's wound vac dressing on Friday because she left early due to the storms. The Treatment Nurse said Resident #218 had not told her the wound vac was not changed. The Treatment Nurse said she did not keep a wound tracking log. The Treatment Nurse said she provided wound treatments when she was in the building. The Treatment Nurse said the circular area on the side of Resident #218's right foot was not there on admission, and today was the first day she had noticed it. The Treatment Nurse said the great toe had been purple for 2-3 days. The Treatment Nurse made observation of the great toe and wounds with this Surveyor. The Treatment Nurse said she did not see a blister on Resident #218's right great toe. The Treatment Nurse said the charge nurses had notified the NP when they had noticed Resident #218's right great toe was purple. The Treatment Nurse said they were monitoring the right great toe daily. The Treatment nurse said the Weekly Skin Assessments were completed by her. The Treatment Nurse said when Resident #218 admitted she completed her initial skin assessment, and she had skin tears to her buttocks. The Treatment Nurse said she felt like the areas had worsened because Resident #218 had been scrubbing her buttocks too hard. The Treatment Nurse said barrier cream was applied to her buttocks. The Treatment Nurse said she did not measure wounds. The Treatment Nurse said when a new wound was identified she would take a picture and send it to the wound care doctor for orders. The Treatment Nurse said she would document it on a skin assessment as an open area. The Treatment Nurse said when the wound care doctor made his rounds he assessed the wounds, staged them, and performed measurements. The Treatment Nurse said Resident #218 was unable to be referred to the wound care doctor at the facility because she was being followed by her cardiologist and surgeon. The Treatment Nurse said Resident #218 had a follow up with her surgeon tomorrow so they would assess her wounds. The Treatment Nurse said Resident #14 had been referred to the wound care doctor for assessment of his open area but had not been seen yet. During an interview on 04/29/24 at 6:07 PM, LVN S said she was off over the weekend, and today was her first day back. LVN S said earlier in the day she had noticed Resident #218's toe started turning black and cold to touch like she was not getting circulation to it. LVN S said she notified the NP, and he instructed her to notify Resident #218's surgeon. LVN S said she had called the surgeon and left a message with his office. LVN S said she had not noticed the area to Resident #218's side of the right foot. LVN S said she had not noticed the blister on Resident #218's right great toe. LVN S said if Resident #218 did not receive appropriate treatment for her toe she could lose it. During an interview on 04/30/24 at 9:44 AM, the NP said he saw Resident #218 Friday 04/26/24, and she had a small sore on her right great toe and it had no capillary refill (circulation), it was pale white. The NP said he believed the wound care doctor was supposed to see Resident #218. The NP said the nurses had notified him of Resident #218's right great toe being dark purple since Friday and yesterday they contacted him again about her right great toe and he had instructed them to contact the surgeon. The NP said he had not been notified about the area to the side of her right foot. The NP said he expected for the staff to monitor the areas on Resident #218's right foot, and he believed they were because they had contacted him about it multiple times over the last 48 hours. The NP said if there was a new pressure ulcer he was notified and an order to consult with wound care was given. The NP said he was sure there were protocols for wounds that the Treatment Nurse followed. The NP said he was not aware of Resident #14's wound to his left buttock. The NP said Resident #47 had wounds since she admitted , and they never fully healed. The NP said they had tried ankle pillows and was seen by a vascular doctor and wound care doctor. The NP said Resident #36 had a stage 2 to his coccyx or buttocks he was not sure. The NP said he was notified he thought last week of it. During an interview on 04/30/24 at 10:26 AM, the DON said when a new wound was found by the nurses they should notify the Treatment Nurse, assess the wound, cover it if needed until the Treatment Nurse could see it. The DON said the Treatment Nurse assessed and measured wounds, and if the wound was pressure related she tried to help stage it, get treatment for it and refer the residents to the wound care doctor. The DON said pictures would be sent to the wound care doctor, so they did not have to wait for a week to treat the wound. The DON said the Treatment Nurse was responsible for wound measurements and she provided oversight. The DON said she tried to see the pressure wounds weekly, and the Treatment Nurse provided her updates weekly on the wounds and wound care and they discussed wounds every day in the morning meeting. The DON said the wounds were tracked in a system in the computer that used the Weekly Ulcer Assessments to generate the tracking data. The DON said the Treatment Nurse completed Weekly Skin Assessments and if the residents had a pressure ulcer the Treatment Nurse completed Weekly Ulcer Assessments. The DON said if the Weekly Ulcer Assessments were not completed the wound tracking data would not be accurate. The DON said she was aware of the right great toe necrotic areas on Resident #218's right foot. She did not know about her right great toe until yesterday. The DON said she was not notified of the ulcer on the side of her right foot. The DON said the nurses should have notified her, the doctor, and contacted wound care. The DON said she was notified yesterday Resident #218 might have a small stage 2 on her buttocks but was not notified of anything else. The DON said Monday-Friday the Treatment Nurse was responsible for the wound care treatments and on the weekends the nurses were responsible. The DON said she was notified of Resident #14's open area to his buttocks today in the morning meeting, and she did not see any measurements in the computer. The DON said when the wound care doctor rounded, he measured the wounds. The DON said she was not aware the Treatment Nurse was not measuring the wounds. The DON said her expectations were for measurements, redness, description of what the wounds were and where it was and how many should be documented. During an interview on 04/30/24 at 11:09 AM, the Treatment Nurse said the facility did not have a protocol for pressure ulcers. During an interview on 05/01/24 at 9:44 AM, the Medical Director said the nursing staff contacted the NP for new wounds and concerns. The Medical Director said they reviewed cases together, but the NP handled most of the facility's needs. During an interview on 05/01/24 at 5:55 PM, LVN M said he did not do any wound care treatments on Friday, including Resident #218. LVN M said he did not do wound care treatments that the Treatment Nurse was responsible for completing them. During an interview on 05/02/24 at 5:44 PM, the Treatment Nurse said not measuring wounds, not completing the ulcer assessments, not identifying wounds promptly, not performing the treatments as ordered and not having accurate treatment could cause wounds to deteriorate and placed the residents at risk for infection. During an interview on 05/02/24 at 7:56 PM the Administrator said he expected for the wounds to be treated based on the orders provided. He expected for them to be staged by an RN, and the location of the wounds to be accurately documented. He expected for the skin assessments to be completed weekly. The Treatment Nurse was responsible for this, and the DON should provide oversight. The Administrator said it was important for these things to be done because if not wounds would not heal and they could worsen, get infected and lead to sepsis. 45879 3. Record review of Resident #47's quarterly MDS assessment, dated 04/09/24, indicated Resident #47 was understood and was understood by others . The MDS assessment indicated she had a BIMS score of 13 indicating Resident #47 cognition was intact. The MDS did not indicate Resident #47 refused care. The MDS indicated he required maximal assistance with toileting, bathing, dressing and hygiene, and set-up assistance with eating. The MDS did not indicate any pressure ulcer during the 7-day look-back period. Record review of Resident #47's physician orders dated 04/25/24 revealed, 24 revealed Left Ankle: Cleanse with Normal saline of wound care cleanser; Pat dry; Apply hydrogel; apply dry dressing. Daily and as needed for Wound Healing. Record review of Resident #47's Medication administration record dated 04/25/24 revealed Left Ankle: Cleanse with Normal saline of wound care cleanser; Pat dry; Apply hydrogel; apply dry dressing. Daily, one time, and as needed for Wound Healing. Record review of Resident #47's comprehensive care plan, dated 02/29/24, indicated Resident #47 had the potential for pressure ulcer development. The interventions were for staff to Educate the resident's family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; the importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Record review of Resident #47's skin assessment dated [DATE] indicated Resident #47 had an open area to her left ankle. Record review of Resident #47's skin assessment dated [DATE] indicated Resident #47 had an abrasion to her right ankle. Record review of Resident #47's wound care report dated 04/19/24 did not reveal any measurements or documentation related to her right ankle. Record review of Resident #47's wound care report dated 04/23/24 revealed a stage 4 to left outer ankle measuring 0.7X1.2X0.1cm (Length X Width X Depth). Record review of Resident #47's wound care report dated 05/01/24 revealed a stage 4 to left lateral ankle measuring 1.0X1.02X0.1cm (Length X Width X Depth). The wound care doctor wrote a progress note which revealed: The progress of this wound and the context surrounding the progress were considered in greater depth today. Discussed pain and pain management strategies with patient, family, and/or care-providing staff. Reviewed off-loading surfaces and discussed surface care plan Record review of Resident #47's electronic medical records did not reveal an ulcer assessment from 04/12/24 through 05/02/24. During an observation and interview on 04/29/24 at 5:28 p.m., Resident #47's left ankle was laying on the bed. Resident #47's left anke was not offloaded. Resident #47 said she did not know anything about her wound except people came in and did something to it. She said it did not hurt. During an interview on 04/30/24 at 3:29 p.m., CNA B said she had never been told to offload Resident #47's left ankles. She said she had not offered any alternative to keeping her left ankle offloaded. During an interview on 04/30/24 at 3:30 p.m., CNA V said she took care of Resident #47 and was unaware she needed to offload her left ankle. During an observation and interview on 04/30/24 starting at 3:33 p.m., Resident #47 was in bed with her left ankle laying on the bed. Resident #47's left ankle was not offloaded. LVN S said she was one of Resident #47's primary day nurses. She said she was unaware Resident #47 had an area on her left ankle until questioned by the surveyor. She said she had not performed any wound care for Resident #47's left ankle. She said anytime a new open area was identified it should be placed on the 24-hour report to inform all nurses of a change in any resident condition. She said she had not attempted anything to keep Resident #47's left ankle offloaded. During an interview and record review on 05/02/24 at 6:49 p.m., the Treatment nurse said she identified an open area to Resident #47's left ankle on 04/12/24. She said she had notified the wound care doctor about Resident #47's left ankle at an unknown time but he did not see her until 04/23/24. She said when the wound care doctor saw Resident #47's left ankle, he said it was a reoccurrence. She said she had treatment in place for her left ankle open area until the wound care doctor made rounds. We reviewed the treatment sheet and no wound care treatments were ordered until 04/25/24. We reviewed the ulcer assessments from 04/12/24 through 04/30/24 and did not see an ulcer assessment related to Resident #47's left ankle. She said she knew she was supposed to complete an ulcer assessment but had not. She said she had been working the floor and trying to keep up with the skin process but was unable to fully complete them both. She said she did not feel she had enough training when she took the wound care position about a month ago. The treatment nurse said at times when she entered Resident #47's room her ankles would not be offloaded. She said she had not done any in-services with staff on offloading Resident #47's heels/ankles. During an interview on 05/02/24 at 6:51 p.m., the DON said the treatment nurse was responsible for the resident's treatments, and assessments. She said she expected wound care to be performed as ordered, and weekly skin and ulcer reports to be done weekly. She said she did not know the ulcer assessments had not been completed as needed. She said it was important to assess the skin weekly to prevent the development of wounds. During an interview on 05/02/24 at 7:54 p.m., the Administrator said he expected the treatment nurse to do weekly skin assessments as ordered. The Administrator said the DON was responsible for ensuring skin assessments were completed. He said failure to complete skin or ulcer assessments could cause residents not to have care done. 45810 4. Record review of Resident #36's face sheet dated 05/02/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of hemiplegia following cerebral infarction (disrupted blood flow to the brain causing paralysis), chronic pain, hypertension (high blood pressure), cognitive communication deficit, and major depression. Record review of Resident #36's quarterly MDS assessment dated [DATE] indicated that she had a BIMS score of 11 which indicated she had moderate cognitive impairment. The MDS also indicated she required maximal assistance with toileting, total assistance with bed mobility and transfers, and setup assistance with eating. The MDS also indicated Resident #36 was at risk for pressure ulcers. Record review of Resident #36's care plan dated 02/20/24 indicated resident had impaired cognitive function/dementia with an intervention for the facility to administer medications as ordered. The care plan also indicated she had an ADL self-care performance deficit and required assistance from staff for toileting, bed mobility, dressing, and bathing. Record review of Resident #36's physician orders as of 04/29/24 indicated She had orders as indicated: Wound to buttocks: Cleanse wound with NS/WC, pat dry, apply Anasept, apply dry dressing one time a day for wound healing that started 04/24/24. Wound to buttocks: Cleanse wound with NS/WC, pat dry, apply Anasept, apply dry dressing as needed for wound healing that started 04/24/24. Record review of Resident #36's treatment administration record dated April 2024 indicated LVN M completed the treatment on 04/26/24 and 04/28/24. Record review of Resident #36's weekly skin assessment dated [DATE] indicated she had redness to her buttock and peri area. Record review of Resident #36's weekly skin assessment dated [DATE] indicated she had an open area to her buttocks with no measurements noted. Record review of Resident #36's wound doctor's initial visit dated 05/01/24 indicated she had an unstageable DTI to the right buttock partial thickness that measured 13cm X 12cm X 0.1cm and a non-pressure wound of the left buttock partial thickness that measured 10cm X 7cm X 0.1cm. During an observation and interview on 04/28/24 at 03:37 PM Resident #36 was lying in bed. CNA UU had provided peri-care and was waiting on nurse to treat wound to Resident #36's buttocks. Resident #36 complained of pain 10 on 1-10 scale so the Treatment Nurse told resident she would medicate her and then provide wound care once the pain was managed. During an interview on 04/29/24 at 09:02 AM Resident #36 said no one placed dressing to her buttocks after she was administered pain medication on 04/28/24. During an observation on 04/29/24 at 09:13 AM during incontinent care provided by CNA UU, Resident #36 had no dressing in place to buttocks. During an interview 04/29/24 at 10:00 AM the Treatment Nurse said the wound doctor came to the facility weekly to complete rounds on residents with wounds. She said she had placed Resident #36 on the list to be seen because the areas to her buttocks are moisture associated skin damage but appear to be on the verge of worsening, but she did not measure any wounds in the facility. She said the DON only looked at pressure wounds. The Treatment Nurse said the wound doctor measured wounds and staged wounds when he saw a resident in the facility. During an observation on 04/29/24 at 03:20 PM the Treatment Nurse provided the treatment to Resident #36's left buttock that measured 8cm X5cm in size and resembled moisture associated skin damage and her right buttock that measured 13cm X 10cm and resembled moisture associated skin damage. During an observation on 04/30/24 at 05:35 PM the Treatment Nurse provided treatment to Resident #36's buttocks with the DON in the room as well. The left buttock measured 10cm X 6.5cm open area that appeared to be a stage 2 ulcer and right buttocks measured 13cm X 10cm and resembled moisture associated skin damage. During an interview on 05/01/24 at 10:47 AM LVN M said the Treatment Nurse performed treatments in the facility on Monday through Friday and sometimes on the weekends. He said when she was not in the facility the DON would notify the floor nurses to complete treatments for their residents. He said he had never completed Resident #36's treatment to her buttock even though he had signed the record on 04/26/24 and 04/28/24. LVN M said failure to complete the treatments could have caused worsening of the area. 5.Record review of Resident #115's face sheet dated 05/02/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses aftercare for genitourinary surgery, hypertension (high blood pressure), and benign prostatic hyperplasia (enlarged prostate). Record review of Resident #115's admission MDS assessment dated [DATE] indicated he had a BIMS score of 15 which indicated he was cognitively intact. The MDS also indicated he required supervision with toileting, dressing, and bathing. Record review of Resident #115's undated care plan indicated he had an ADL self-care deficit and required assistance by 1 staff for bathing, dressing, toileting, and personal hygiene. The care plan also indicated he had a pressure ulcer to his left buttock, and he was on enhanced barrier precautions with interventions of gloves and gown to be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing . Record review of Resident #115's order summary report dated 04/2924 indicated he had an inaccurate location order as indicated: Wound to right buttock: Cleanse wound with NS/WC, pat dry, apply calcium alginate with silver and cover with a border gauze one time a day for wound healing with a start date of 04/25/24. Wound to right buttock: Cleanse wound with NS/WC, pat dry, apply calcium alginate with silver and cover with a border gauze as needed for wound healing with a start date of 04/24/24. Record review of Resident #115's weekly skin assessment dated [DATE] indicated he had a pressure ulcer, but it did not indicate a location or measurements. Record review of Resident #115's weekly ulcer assessment dated [DATE] inaccurately indicated he had a stage 3 pressure area to his right buttocks when in fact the pressure ulcer was located on his left buttock. During an observation on 04/28/24 at 04:25 PM revealed Resident #115 lying in bed. He said his wound care was not done yesterday or days before. Resident #115 showed the surveyor his left buttocks and the bandage was dated 4/25/24. During an observation on 04/28/24 at 05:05 PM the Treatment Nurse went into Resident #115's room and provided the treatment to his left hip using good technique. When she removed the old dressing surveyor asked the date on the dressing and it was dated 04/25/24. During an interview on 04/28/24 at 05:12 PM The Treatment Nurse said she had to leave the facility early on Friday 04/26/24 and the charge nurse was responsible for providing wound care on Friday 4/26/24-04/28/24. She said the failure of the treatments not being completed placed a risk for infection. During an interview on 05/01/24 at 10:47 AM LVN M said the Treatment Nurse performed treatments in the facility on Monday through Friday and sometimes on the weekends. He said when she was not in the facility the DON would notify the floor nurses to complete treatments for their residents. He said he had never completed Resident #115's treatment to his buttock even though he had signed the record on 04/26/24 and 04/28/24. LVN M said failure to complete the treatments could have caused worsening of the area. Record review of the facility's policy titled, Skin Integrity Management, revised October 5, 2016, indicated, 1. If pressure causes changes in the resident's skin, it is the responsibility of the charge nurse to document on the 24-Hour Report form and initiate Protocols for Pressure Sores. Notify the Treatment Nurse/designee, then do an assessment and initiate a treatment plan as soon as possible. Document in resident's chart, area of change, who you notified, and treatment applied. 2. Pressure Sore, Localized Rash and Skin Tears may be utilized if the attending physician has approved. Long Term Care Protocol drives an assessment and gathers information for reporting and permits treatment to begin in a timely manner. If the attending physician has not approved these protocols, continue with the protocols in this policy a[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 4 of 14 residents (Residents #42, #165, #58, and 115) reviewed for accident hazards. 1. The facility failed to ensure safety measures were in place after Resident #42 received a first-degree burn (an injury that affects the first layer of your skin) from hot coffee. An Immediate Jeopardy (IJ) situation was identified on 05/01/24. The IJ template was provided to the facility on [DATE] at 11:41 a.m., While the IJ was removed on 05/02/24 at 5:15 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. 2. The facility failed to ensure Resident #165 was supervised while smoking. 3. The facility failed to ensure Resident #58 did not keep cigarettes and a lighter. 4. The facility failed to ensure Resident #115 did not keep cigarettes and a lighter. These failures could place residents at risk for serious burns, infection, and even death. Findings included: 1.Record review of Resident #42's face sheet dated 05/02/24, indicated a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and stiffness), Chronic obstructive pulmonary disease, or COPD, (a group of diseases that cause airflow blockage and breathing-related problems), and Heart failure (occurs when the heart muscle doesn't pump blood as well as it should). Record review of Resident #42's admission MDS assessment dated [DATE], indicated she understood and was understood by others. Resident #42 had a BIMs score of 12 indicating she was moderately cognitively impaired. The MDS indicated Resident #42 required set-up assistance with personal hygiene and eating. Record review of Resident #42's comprehensive care plan dated 04/15/24, indicated she had potential impairment to skin integrity related to fragile . The interventions were for staff to educate the resident/family and caregivers of causative factors and measures to prevent skin injury. Record review of Resident #42's comprehensive care plan dated 05/01/24, (after surveyor intervention) indicated she was at risk of burns due to hot liquids. The intervention was for her to use a specialized cup with a lid for hot liquids to prevent spills and for staff to provide observation and verbal assistance when she had hot liquids. Record review of Resident #42's incident report on 04/30/24 at 5:15 p.m. revealed she had obtained a burn on 03/03/24. The incident report stated Resident #42 had just gotten a cup of coffee and her hand started shaking causing her to spill her coffee. The incident report failed to provide a description and measurements of the burn. The incident report revealed LVN F applied normal saline and barrier cream to Resident #42's abdomen. The incident report failed to provide interventions to prevent Resident #42 from sustaining further burns. During an interview on 04/30/24 at 5:26 p.m., the Dietary Manager said they had been checking the coffee before Resident #42's burn. She said they usually did 2 coffee pots at a time but only recorded the coffee temperatures of 1 coffee pot even if they made 2. She said she was not aware of Resident #42's burn until an unknown time later. She said she had reviewed the coffee temperature log on the day of the burn and the temperature was recorded at 133 degrees. She said on 03/03/24 she had a new employee and was not sure if she tested both coffee pots that day. She said she had not been in-serviced to change her coffee process in the kitchen. During an interview on 04/30/24 at 5:52 p.m., LVN F said Resident #42 was rolling in her wheelchair in the dining room when she spilled hot coffee on herself. She said Resident #42 got her own coffee. She said she removed Resident #42's shirt and assessed her abdomen. She said she had a small red area across her abdomen. She said she placed some cream on it but could not remember what type of cream. She said on 03/03/24 she monitored and observed Resident #42's burn area for any changes. She said she completed an incident report and notified the family, the DON, and the doctor. She said she was unaware of the kitchen's process for coffee. She said she did not remember an in-service on coffee burns after Resident #42 received the burn on 03/03/24. During an interview on 04/30/24 at 6:12 p.m., Resident #42 said she went to the kitchen to get her some coffee. She said she used the regular coffee cup. She said on 03/03/24 her hands were weak and she lost grip on the coffee cup causing her to spill the coffee across her abdomen. She said the nurse did look at the area on her abdomen and placed some cream on it. She said it felt better afterwards but it felt like it was burning the rest of the day afterwards. She said by morning it was better. She said she does not remember anyone saying anything about the coffee other than the nurse who assessed her. She said she still gets her coffee but she has not had any trouble since. This surveyor observed Resident # 42 take a few bites of her lunch and saw a little shakiness when attempting to put her fork down. During an interview on 04/30/24 at 6:19 p.m., the DON said Resident #42 could get her own coffee. She said the nurse assessed the area and it was fine. She said they did not do any in-services or attempts to change how coffee was served. She said Resident #42's care plan should have been updated after the burn. She said she had never heard of any assessments about hot liquids. She said she did not know the policy on hot coffee. She said she would have to review the policy. During an interview on 04/30/24 at 6:21 p.m., the Administrator in training said the nurses assessed the area and it was red and there was nothing else that needed to be done as far as he knew for Resident #42. He said the kitchen temped the coffee and it should not go out to the dining room until checked. He said the coffee should be below 155 degrees but was not 100% sure. He said he did not recall any other steps they did to ensure other residents were not at risk of burns. During an observation and interview on 05/01/24 at 7:16 a.m., Cook X tested coffee pot #1 at 154 degrees and tested coffee pot #2 at 99.1 degrees. She said she brought the coffee #2 pot out at about 5:30am and the dietary aide brought the other coffee out at 6:30am. She said she did not normally do the coffee. She said she knew they had to temp the coffee before they brought it out of the kitchen and it was supposed to be 140 degrees and lower. During an interview on 05/01/24 at 7:20 a.m., dietary aide W said she placed ice in the coffee before she brought it out of the kitchen. She said she guessed she did not place the thermometer far enough in the coffee pot to have an accurate temperature. She said they usually bring out 3 or 4 coffee pots in the morning. She took the coffee back into the kitchen. During an interview on 05/01/24 at 9:42 a.m., the physician said he heard about Resident #42's burn at some point but he expected the facility to reach out to the NP first. He said if the NP had an issue that he could not solve then the NP would reach out to him. He said redness from the coffee spill was considered a first-degree burn. During an interview on 05/01/24 at 6:32 p.m., the NP said he could not remember about the coffee spill or burn for Resident #42 but was sure the facility notified him. He said he could not remember if he ordered anything or not because it was too far ago to remember. Record review of facility policy titled Hot Liquid Spill, indicated Residents are at risk of having any hot liquid food spilled on their person causing bums Examples of hot liquids/food are: coffee. tea, hot soup, oatmeal. or any other hot food or liquid substance. If any staff member observes a resident spill hot liquid or food on themselves or another resident. The staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at room temperature or below, by pouring the room temperature or cooler liquid directly on the area affected. 2. The charge nurse is to be immediately notified so that an assessment of the resident can be completed 3. The charge nurse will report any injury to the attending physician and responsible party and follow any further physician orders 4. Staff will assist with changing clothes as needed. An incident report and investigation will then be completed and determine if the resident needs further interventions to prevent future occurrences. An IJ was identified on 05/01/24 at 11:40 a.m. The IJ template was provided to the facility on [DATE] at 11:41 a.m. The Facility's plan of removal was accepted on 05/02/24 at 11:02 a.m. and included the following: Record review of facility QAPI committee indicated: A system failure was identified: On 05/01/2024 during an Annual survey the Survey Team identified a failure of the Facility to prevent burns due to hot liquids or hot foods. Areas of concern that were identified are listed below for review. The Facility failed to: 1. Update 1 resident's care plan 2. Assess 1 resident for hot liquid safety. 3. Identify at-risk residents. 4. Implement measures to prevent other coffee spills with burns. ADO and RNC initiated an action plan on 5/01/2024 to ensure all policy related policy, education of staff, and a plan of sustainability and monitoring is in place with a compliance goal of 5/2/2024. Once compliance is established, Administrator/Designee will monitor coffee is served to ensure safe temperature. Administrator is responsible for creating a safe environment for residents to include service of hot liquids/hot foods. Date: 5/1/24 Problem: F689 Free of Accidents/Hazards/Supervision Interventions: o Resident's #42 care plan was updated to include at risk for coffee burn and specialized cup with a lid to help prevent coffee spills as of 5/1/24 by the DON. o Resident's #42 hot liquid assessment was completed as of 5/1/24 by the DON. o Hot liquid Assessments were updated on all residents in the facility the DON on 5/1/24. o Residents at high risk for coffee burns were assessed for the need of assistive devices if consuming hot liquids on 5/1/24. Care plans were updated as of 5/1/24 by the DON/Regional Compliance Nurse. o The medical director was notified of the situation on 5/1/24 by the administrator. o An off cycle QAPI meeting was completed with the IDT team and medical director to discuss the immediate jeopardy and plan of removal. In-services: The ADO will in-service the Administrator and Dietary Manager 1:1 on the following topics on 5/1/24. o All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees. Coffee will not be served over 140 degrees. All brewed coffee will have the temperature logged before serving. o Hot liquid Spills Policy o Guidelines on serving coffee in a nursing facility policy The following in-services were initiated by Administrator, DON, ADON on 5/1/24 for all staff. Any staff member not present or in-serviced on 5/1/24, will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced in orientation. All agency staff will be in-serviced prior to assuming shift. o All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees. Coffee will not be served over 140 degrees. All brewed coffee will have the temperature logged before serving. o Hot liquid Spills Policy o Guidelines on serving coffee in a nursing facility policy Monitoring: The administrator will be responsible daily for ensuring the coffee temperature will be checked and logged prior to serving / making coffee available to residents. Coffee will not be served until the temperature is between 135- 140 degrees. In-Service Training Topic: All brewed coffee will have ice added until internal temp reaches 135-140 degrees, Coffee will not be served over 140 degrees, all brewed coffee will have the temperature logged before serving. Guidelines on Serving Coffee in the Nursing Facility 1. As there is no published federal or state regulation for minimum or maximum coffee temperature, the decision as to the temperature at which to serve the coffee rests with the administration of each facility, based on their resident's stated preferences, and the physical layout of their building, but balanced against the safety of their individual residents and their physical and mental limitations. 2. The standard for coffee service will be 140 degrees, unless the facility's residents have stated an overwhelming preference for coffee to be served at a higher temperature and additional safety measures have been implemented, or the safety of residents warrants a lower temperature. If coffee is served at 140 degrees, it will cool to 136 degrees when dispensed into a room temperature coffee cup or mug, and per 'Time and Temperature Relationship to Serious Burn from the American Burn Association website, this temperature will allow approximately 15 seconds before a serious burn will occur, based on the physical condition of the individual person. 3. Any residents who have risk factors for coffee burns, such as significant cognitive impairment or extreme shaking may be evaluated for additional safety precautions using a hot beverage risk assessment. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability. 4. If coffee is served and held at a temperature lower than 140 degrees, then it will be discarded after four hours and its dispenser cleaned and sanitized before fresh coffee is added. 5. An investigation and evaluation will be performed for any resident who receives a coffee bum, and a plan to reduce this resident's risk or receiving future burns will be developed and implemented. 6. If local, state, or federal regulations or guidelines for coffee temperatures are developed and/or published, then these standards will become the practice at the facility. Until that time, the facility administration must honor the resident's right to make risky decisions but balance decisions against individual safety. Monitoring : Interviews on 05/02/24 from 1:00 p.m. until 5:00 p.m. revealed the following: Record review of in-service on the hot liquid process and signatures of staff who had been in-serviced. Interview s with 2 RNs: DON and RN E,7 LVN's(LVN M,JJ,N,S,KK,B,N),7 CNAS (CNAs-MM,NN,OO,V,C,R,PP) 1restorative aide,(L) 2 student aides(O,H), 1 Med aide (II), Hospitality aide (HH), 2 laundry staff (FF,GG), 2 housekeeping staff and supervisor (DD,EE), 7 dietary staff and supervisor (W,Z,AA,X,Y,BB,CC), the HR, SW, MDS ,BOM and the Administrator all stated they had been in-serviced about the hot liquid process and what to do if someone spills coffee and things, they can use to prevent coffee spills. During a phone interview on 05/02/24 at 5:00 p.m., the medical doctor said he was aware of the IJ given related to the coffee burn and they had a QAPI meeting. Record review of the monitoring of the hot liquids signed by the Administrator started 05/01/24. Record review of the coffee temperature log started 05/01/24 revealed staff had been checking the coffee before placing in the kitchen area. Record review of the hot liquid assessment done by the facility for 68 residents. 4 residents were identified at risk of hot liquid spills (Residents #42, #4, #20 and #40). On 05/02/24 at 5:15 p.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm that was not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 2.Record review of Resident #165's face sheet, dated 05/02/24 indicated Resident #165 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Fracture of the right leg, Diabetes, Coronary artery disease {CAD} (narrowing or blockage of your coronary arteries, which supply oxygen-rich blood to your heart), and hypertension (high blood pressure). Record review of Resident #165's electronic health record on 05/02/2024 indicated the MDS assessment had not been completed yet. Record review of Resident #165's comprehensive care plan, dated 04/27/24 indicated Resident #165 was a smoker. The intervention of the care plan was for staff to supervise while smoking. Record review of Resident #165's smoking assessment completed on 04/24/24 indicated he required supervision while smoking. During an observation and interview on 04/29/24 at 06:40 p.m., this surveyor observed Resident #165 outside smoking without the supervision of a staff member. This surveyor went to get the DON who assigned a staff member to go outside with Resident #165. The DON said he was not supposed to be outside smoking without supervision for safety reasons and she said she was not aware how he obtained his cigarettes or lighter. The MDS nurse came outside to supervise Resident #165 as he completed his cigarettes. She said his care plan indicated he was supposed to be supervised when smoking. She said she did not know how he got his cigarettes or lighter. She said this was a safety hazard. During an interview on 05/02/24 at 7:25 p.m., the Administrator said residents who are supposed to be supervised should not have possession of their cigarettes or lighters. He said the nurses were supposed to be responsible for the distribution of cigarettes and lighters. He said they needed to work on the smoking process. He said if residents had their lighters and or cigarettes it could be a safety issue for them and others. 46892 3. Record review of a face sheet dated 05/02/24 indicated Resident #58 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood) and polyneuropathy (damage to nerves throughout the body). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #58 was able to make himself understood and understood others. The MDS assessment indicated Resident #58 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #58 required setup or clean-up assistance with eating, oral, personal, and toileting hygiene, showering/bathing self and was independent for dressing himself. The MDS assessment indicated Resident #58 currently used tobacco. Record review of Resident #58's care plan last review completed on 04/03/24 indicated he smoked. Interventions included to ensure smoking occurs in designated smoking area, ensure that the resident and/or responsible party is made aware of the facility smoking policy, and safe smoking assessment every month. Record review of Resident #58's Safe Smoking assessment dated [DATE] indicated the resident was able to smoke independently and was able to independently light smoking materials safely. Resident #58's smoking assessment indicated he was safe to smoke unsupervised at this time. During an observation and interview on 05/01/24 starting at 7:15 AM, Resident #58 said he was allowed to smoke alone outside if state (state surveyors) was not in the building. Resident #58 had cigarettes and a lighter on him. During an interview on 05/01/24 starting at 7:24 AM, AIT said he did not know Resident #58 had cigarettes and a lighter. The AIT said he was not sure if he was allowed to keep them that he would find out the right answer. During an interview on 05/01/24 at 7:30 AM, Resident #58 said he did not have any lighters or cigarettes with him. During an observation on 05/01/24 at 7:32 AM, Resident #58 was observed walking down the hall and going out to the smoking area and started smoking. Nobody else was in the smoking area. During an interview on 05/01/24 at 7:36 AM, this Surveyor informed the Administrator of the observations made of Resident #58 going from his room to the smoking area to smoke. Resident #58 had his own cigarettes and lit his cigarette. The Administrator said the residents were not supposed to keep cigarettes or lighters per their policy. The Administrator said the facility staff kept the cigarettes and lighters, and the residents had to request them when going out to smoke. The Administrator said the residents should not keep cigarettes or lighters because they could light up a cigarette in the building and catch it on fire. During an interview on 05/02/24 at 6:32 PM, the DON said the residents were not supposed to keep lighters or cigarettes. The DON said sometimes the family brought the residents lighters and cigarettes and they could not make the residents give the lighters and cigarettes to them. The DON said if they had someone that repetitively was keeping cigarettes and lighters, they did not want to discharge them because they did not want to lose residents. The DON said all the staff were responsible for ensuring the residents were not keeping lighters and cigarettes. The DON said they had issues with residents keeping cigarettes and lighters on them. The DON said they implemented a smoking box, and the residents were supposed to follow the smoking times, but she could not keep the residents from going outside to smoke. The DON said if the residents kept cigarettes and lighters, they could catch the building on fire and burn themselves. 45810 4.Record review of Resident #115's face sheet dated 05/02/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses aftercare for genitourinary surgery, hypertension (high blood pressure), and benign prostatic hyperplasia (enlarged prostate). Record review of Resident #115's electronic medical record indicated the MDS assessment was not due to be completed. Record review of Resident #115's undated care plan indicated he had an ADL self-care deficit and required assistance by 1 staff for bathing, dressing, toileting, and personal hygiene. The care plan also indicated he was a smoker with interventions for the resident to keep all smoking material at the nurse's station. During an observation and interview on 04/30/24 at 12:10 PM Resident #115 was sitting in his chair beside his bed and he had a neon green lighter and a box of [NAME] sweet cigars on his bedside table. Resident #115 said he had just returned from smoking and kept his own lighter and smokes. During an interview on 04/30/24 at 12:18 PM LVN F was told by surveyor that Resident #115 had his lighter and cigars. LVN F said he should not have had the items in his room, and the cigars and lighter should have been kept at the nurse's station. She said she was serving the dining room at that time but would notify someone to retrieve the items. During an observation on 04/30/24 at 12:24 PM the DON and Social Worker entered Resident #115's room and the DON told resident she was removing his lighter and cigars and placing them in a safe place. She told him he could get them from the designated staff when he went to the next smoke break. During an interview on 05/02/24 at 05:47 PM LVN B said no residents are allowed to keep cigarettes nor lighters in their rooms, but she was unsure of the policy. She said the failure placed a risk for resident who wandered to be unsafe, and placed a risk for accidents for residents with oxygen. LVN B said all smoking items should have been kept at the nurse's station. During an interview on 05/02/24 at 06:32 PM the DON said cigarettes and lighters were not supposed to be in the residents' rooms. She said she could not dig in the resident's personal items and could not body check the residents to get the smoking items from them. The DON said everyone was responsible for ensuring residents do not have smoking items in the rooms. She said the facility had a smoking box at the nurse's station for all the items and they had a smoking schedule with scheduled staff to take the residents out for smoke breaks. The DON said the failure placed a risk for residents catching the building on fire or getting unexpected burns. During an interview on 05/02/24 at 08:33 PM The Administrator said his expectation was for no residents to have any cigarettes or lighters in their possession. He said the facility had a box at the nurse's station for the smoking items. He said the failure placed the residents at risk for burns, fire hazards, or residents setting the place on fire. The Administrator said all staff were responsible for ensuring there were no smoking items on residents or in rooms. Record review of the facility Smoking Policy revised 04/25/2022 indicated: Smoking policies must be formulated and adopted by the facility . The facility was responsible for enforcement of smoking policies which must include at least the following provisions. 1. Smoking tobacco, matches, lighters, or other ignition sources for smoking are not permitted to be kept or stored in resident's room. 2. A safe smoking assessment will be done regularly for each resident who smokes . 3. If the facility identifies that the resident needs assistance/supervision and/or additional protective devices for smoking .

Based on interview and record review the facility failed to ensure laboratory services were obtained to meet the needs for 1 of 5 (Resident #1) residents reviewed for laboratory services. The facility did not ensure Resident #1 had weekly CBC (complete blood count-used to look at overall health and find a wide range of conditions including anemia (condition in which the blood does not have enough healthy red blood cells) and infection and BMP (basic metabolic panel-test that checks the body's fluid balance and levels of electrolytes) lab tests as ordered. Resident #1 was lethargic and requested to be sent to the hospital on 2/20/24 where she was admitted for hyponatremia (decreased sodium with symptoms including fatigue, lethargy, and mental confusion), dehydration and AKI (acute kidney injury-a condition in which the kidneys suddenly cannot filter waste from the blood. Resident #1 did not receive her weekly lab draws as ordered on the weeks of 1/15/24-1/19/24, 1/22/24-1/26/24, 1/29/24-2/2/24, 2/5/24-2/9/24, and 2/12/24-2/16/24. An Immediate Jeopardy (IJ) was identified on 3/5/24 at 12:00 p.m. While the IJ was removed on 3/6/24, the facility remained out of compliance at a with a scope identified as pattern and severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the residents at risk of not receiving lab services as ordered and suffering from an undetected infection, decreased electrolyte balances, dehydration, and decreased kidney function. Findings included: Record review of the face sheet dated 3/5/24 indicated Resident #1 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including dementia, diabetes, COPD, hydronephrosis, and chronic pain. Record review of the physician orders 3/5/24 indicated Resident #1 had an order for a CBC and BMP weekly starting 12/15/23. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 9 and was moderately cognitively impaired. Record review of the care plan revised on 12/18/23 indicated Resident #1 had a potential fluid deficit with interventions including obtain and monitor lab/diagnostic work as ordered and monitor/document/report to the physician signs and symptoms of fluid deficits including but not limited to: decreased or no urine output, cracked lips, new onset of confusion, and fatigue/weakness. Record review of the NP progress note dated 2/20/24 indicated, . [The family] stated that [Resident #1] complained to feeling very weak and usually when she complained of this, she needed s blood transfusion. [The family] also noted that [Resident #1] was complaining of hip pain .Offered to order stat labs and x-ray but [the family] declined. Stated that [Resident #1] wanted to go to the hospital. Gave order to nurse send patient to the hospital. Record review of the hospital records dated 2/20/24 indicated Resident #1 presented to the ED with a chief complaint of generalized weakness. The hospital records indicated Resident #1 had a blood pressure of 76/61 (normal blood pressure-120/80) at 5:26 p.m., 95/51 at 5:45 p.m., and 107/62 at 5:56 p.m. The hospital records indicated Resident #1 had a sodium level of 121 (normal sodium level range 135-145) and a creatinine (a blood test to measure creatinine levels in the blood. This test was done to see how well the kidneys were working) level of 3.08 (normal creatinine level 0.7-1.2. The hospital records indicated Resident #1 had lab work significant for hypovolemia (condition in which the liquid portion of the blood is too low), hyponatremia, and acute kidney injury. The hospital records indicated Resident #1 received a total of 2.2. liters of IV fluid bolus (a single dose of fluid or medication administered of a short time), and her blood pressure was currently in the 130s. During an interview on 3/5/24 at 9:47 am the DON said nursing was responsible for ensuring labs were drawn as ordered. The DON said lab orders were entered in the computer and when lab came in the mornings the nurses knew who needed lab draws. The DON said Resident #1 had gone out to the hospital on 1/3/24 and the lab cancelled her routine lab draws. The DON said the facility should have contacted the lab and had the routine lab draws for Resident #1 restarted when she readmitted to the facility on [DATE]. The DON said the importance routine BMPs was to check kidney function, sodium levels, and for dehydration. The DON said the average turnaround time for stat lab results from the mobile lab was 8-12 hours. During an interview on 3/5/24 at 10:28 a.m. the Medical Director stated he would probably expect the facility to resume lab orders if they were weekly when a resident returned from the hospital. The Medical Director said a CBC checked for anemia BMP checked for kidney function and potassium level. The Medical Director said for a sodium level of 121 it would depend on resident's history if he was concerned or felt treatment was needed. The Medical Director said if the sodium level was 119 or 120, he would further investigate what was going on with a resident. The Medical Director said he was not familiar with resident with Resident #1. The Medical Director said sodium can decrease rapidly. The Medical Director said he was unsure if weekly labs would have detected a sodium level declining. The Medical Director said it would depend on the resident. The Medical Director said the best-case scenario for stat labs at the facility was 12 hours. The Medical Director said it would depend on how rapidly sodium levels were dropping to know if delay in stat labs would have affected the resident. During an interview on 3/5/24 at 1:21 p.m. CNA C said she had worked at the facility since October 2021. CNA C said she usually worked the 200 hall. CNA C said she was familiar with Resident #1. CNA C said Resident #1 kept to herself and would not use the call light. CNA C said Resident #1 always received juice at meals and always asked for extra juice. CNA C said Resident #1 would tell her she needed the juice. CNA C said Resident #1 always had juice or milk at her bedside. CNA C said the last couple weeks Resident #1 was at the facility she had stopped asking for extra juice and stopped drinking her juice. CNA C said approximately a week prior to Resident #1 going to the hospital on 2/20/24 Resident #1 had told CNA C she thought she needed to go to the hospital because she did not feel good and felt weak. CNA C said she reported Resident #1's request and concerns to the charge nurse. CNA C said she did not remember who the charge nurse was that day. CNA C said Resident #1 did not get sent out to the hospital the day she requested to regarding not feeling well and feeling weak. During an interview on 3/5/24 at 1:35 p.m. RN B said she had worked at the facility for about a month. RN B said when a resident readmitted to the facility the admitting nurse would contact the physician, if physician wanted to resume all previous ordered including routine labs the admitting nurse would ensure the orders were in the computer, and then complete a new lab requisition to resume scheduled labs. RN B said routine CBCs were to check to make sure a resident was not bleeding out or had an infection and routine BMP was to check kidney function. Record review of the facility's Admission/Readmission policy dated 2003 indicated, .Readmission to a facility occurs after a hospitalization or therapeutic leave. Readmission involves a review of the initial admission data with reinforcement where needed and an update of information regarding health status .Notify attending physician of the admission. Compile a new clinical record and document pertinent admission information . Record review of the facility's Physician's Orders policy dated 2015 indicated, Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident .Nurse will review the order and if needed contact the prescriber for any clarifications. The nurse will enter the order into [the electronic medical records] for the resident .The receiving nurse will contact any other department or external facilities as required, i.e., dietary department, pharmacy, lab provider, x-ray provider, etc. The Administrator was notified on 3/5/24 at 12:13 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 3/5/24 at 12:17 p.m. The facility's Plan of Removal was accepted on 3/5/24 at 6:21 p.m. and included: Interventions: o Resident #1 has been transferred to another facility as of 3/5/24. o A complete audit of all lab orders was performed by the Regional Compliance Nurse, DON, and ADON on 3/5/24 to ensure all labs orders are scheduled to be drawn by the lab company. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on 3/5/24. o Reconciling admission and readmission orders to include labs. The charge nurse will be responsible for reconciling the lab orders with the physician, calling the lab company, and restarting the labs. The DON will be responsible for calling the lab company, reviewing/overseeing all orders, including labs daily to ensure they are restarted. This will be completed 7 days per week by the DON or designee for weekends. o Following physician orders to include labs. o The medical director was notified of the immediate jeopardy situation on 3/5/24. o An ADHOC QAPI (When needed Quality Assurance and Performance Improvement) meeting was completed by the QA committee to include the medical director on 3/5/24 to discuss the immediate jeopardy and subsequent plan. In-services: o The following in-services were initiated by the Administrator, DON, and Regional Compliance Nurse on 3/5/24 for Charge Nurses. All Charge Nurses not present on 3/5/24 will be in-serviced prior to the start of next shift. All new hires will be in-serviced during orientation. All agency staff will be in-serviced prior to the start of their shift. In-services will be completed on 3/5/24. No staff will be allowed to work their scheduled until in-serviced. o Reconciling admission and readmission orders to include labs. The charge nurse will be responsible for reconciling the lab orders with the physician, calling the lab company, and restarting the labs. The DON will be responsible for calling the lab company, reviewing/overseeing all orders, including labs daily to ensure they are restarted. This will be completed 7 days per week by the DON or designee for weekends. o Following physician orders to include labs. Monitoring: The DON, ADON, or Designee will monitor the order report to include labs daily 7 days per week & as needed indefinitely. This process was part of our daily morning clinical meeting. On 3/6/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of an undated Off Cycle QA Meeting Sign-in Sheet indicated the facility had an ADHIC QA Meeting with the Medical Director, AIT, DON, MDS Nurse, Admission Coordinator, and the ADON present . Interviews between 9:03 am and 10:55 am with staff (LVN D, RN E, RN B, LVN F, LVN G, RN H, LVN J, ADON) they said when a resident admitted or readmitted to the facility their orders should be reconciled and confirmed with the physician or PA (Physician Assistant). Staff said all orders should be put in the electronic medical records and relayed on the 24-hour report Record review of a random sample of 15 resident's orders and lab requisitions indicated a new lab requisition had been made and placed in the lab book for each lab order in a resident's electronic medical record. During an interview on 3/6/24 at 10:53 a.m. the DON said she was in-serviced regarding the importance of ensuring labs were completed as ordered, orders were reconciled when a resident admitted or readmitted to the facility, lab requisitions were completed to restart any routine labs or perform any one-time lab draws, and to monitor labs to ensure they are completed as ordered. The DON said she would have a binder for residents with routine labs indicating what month or week they were due and would check it daily to ensure routine labs were performed as ordered. The DON said for stat or one-time order labs there would be a log placed in the lab requisition book that she and the charge nurses would check daily to ensure labs were performed as ordered. On 3/6/24 at 11:11 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance with a scope identified as pattern and severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care, in accordance with the comprehensive care plan and professional standards of practice was provided for 1 of 4 residents reviewed for assessment. (Resident #1) RN A did not comprehensively assess Resident #1 after staff repeatedly informed her throughout the day, the resident did not look himself, had cool and clammy skin, and appeared to have trouble breathing. Resident #1 was assessed by another nurse and was transferred to the hospital where he died less than 2 hours later. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm at a pattern of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place other residents with a change in condition at risk for not receiving care and services to meet their needs, serious impairment, and death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted [DATE], and had [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had severely impaired cognition, usually understood others, and usually made his needs known. Resident #1 required extensive assistance with ADLs. The MDS indicated Resident #1 had no shortness of breath or trouble breathing and no condition that might result in a life expectancy of less than 6 months. A care plan revised on [DATE] indicated Resident #1 had [MEDICAL CONDITION] and interventions included check breath sounds and monitor/document for labored breathing. Monitor/document/report to the physician as needed any symptoms of [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, weakness, crackles and wheezes, increased heart rate, lethargy, and disorientation. Physician orders [REDACTED].#1 had orders including a full code status and [MEDICATION NAME] sulfate nebulizer 2.5 mg/3 ml every 6 hours as needed for cough/congestion. A situation background assessment recommendation (SBAR) report completed by RN A and dated [DATE] at 6:08 p.m. indicated Resident #1 had a respiratory and cardiovascular change. The report indicated Resident #1's vital signs (taken by RN B) were; blood pressure ,[DATE] (normal ,[DATE]) , pulse 132 (normal ,[DATE]) and irregular, respiration rate 32 (normal ,[DATE]) breaths a minute, and oxygen saturation 91% (,[DATE]) on room air. The SBAR indicated Resident #1 was administered an [MEDICATION NAME] nebulizer treatment. Resident #1's NP was notified and ordered the resident to be sent to the hospital. A transfer form dated [DATE] indicated Resident #1 was transferred to a local hospital, was lethargic and had unclear or no speech. Resident #1's wife was notified of the transfer. An EMS record dated [DATE] for Resident #1 indicated the EMS received a call from the facility on [DATE] at 5:36 p.m. and arrived at the facility at 5:47 p.m. The EMS record indicated Resident #1 had altered mental status and acute respiratory distress. Resident #1's blood pressure was ,[DATE], pulse 128, respiratory rate was 24 breaths a minute, and oxygen saturation was 89%. A 12 lead EKG (used to assess the heart) indicated a right bundle branch block (a blockage along the pathway that electrical impulses travel to make the heart beat) and sinus [MEDICAL CONDITION](increased heart rate). The EMS record indicated Resident #1 was unresponsive, had mottled and pale skin, weakness in all 4 extremities (arms and legs), and a thready (difficult to feel) pulse. The EMS record indicated EMS left the facility with Resident #1 at 6:07 p.m. and arrived at the hospital at 6:21 p.m. Hospital emergency department (ED) records dated [DATE] indicated Resident #1 arrived at the ED on [DATE] at 6:26 p.m. Resident #1's white blood cell count was 16.6 (normal range between 4 and 11), b-type natriuretic peptide (BNP) (blood test that reveals heart failure severity) 411.9 (normal range is less than 100 pg/ml), and Troponin I(blood marker that indicates a [MEDICAL CONDITION]) was 0.10 (normal range is less than 0.04 ng/ml). Resident #1's respiratory rate started to slow at 7:50 p.m. The record indicated Resident #1 lost pulse and cardiopulmonary resuscitation (CPR) was initiated at 7:54 p.m. Resident #1 expired in the ED. During an interview on [DATE] at 4:57 p.m., RN C said she was a nurse supervisor and worked on [DATE]. She said on [DATE] she was in the dining room during the lunch meal feeding Resident #1. She said Resident #1 did not look right, his color was off, and he was not eating his meal like he normally did. RN C said Resident #1 normally gobbled his food but during lunch he only ate a few bites and was not swallowing his food. She said Resident #1's charge nurse, RN A was in the dining room and she asked RN A to come look at Resident #1. She said she told RN A Resident #1 was not eating, and the resident did not look right. RN C said RN A said Resident #1 overheated and she would give him a breathing treatment. She said RN A took Resident #1 out of the dining room in his geriatric chair. During an interview on [DATE] at 1:45 p.m., RN A said she worked on [DATE] from 6:00 a.m. to 10:00 p.m. She said RN C was feeding Resident #1 lunch in the dining room and notified her Resident #1 did not look right. RN A said she took Resident #1 out of the dining room and listened to his lungs and checked his respiratory rate. She said his respirations were 30 breaths a minute and that was not normal for him. She said his respirations were normally between ,[DATE] breaths a minute. She said Resident #1 was wearing a long sleeve shirt and she changed his shirt because he would get overheated. RN A said she and a NA transferred the resident to his bed and he continued to breath rapidly. She said his lungs were clear and she administered a breathing treatment (prescribed for cough and congestion) around 1:00 p.m. She said she stayed with the resident for about 15 minutes and his respirations slowed to 20 breaths a minute and the resident fell asleep during the breathing treatment. She said she continued to check on the resident hourly and he slept for the next 2 hours. RN A said the resident was stable and no staff reported any concerns about the resident. She said around 5:00 p.m. the CNAs got Resident #1 up for dinner and RN B told her Resident #1 needed to be sent to the hospital. She said Resident #1's skin was pale, but it was always pale. She said she would have sent the resident to the hospital at lunch if the breathing treatment did not help. She said she did not document any assessments or vital signs because she had another resident with behaviors that she was dealing with. A treatment administration record dated [DATE] did not indicate Resident #1 received an [MEDICATION NAME] sulfate nebulizer on [DATE]. The clinical record on [DATE] for Resident #1 indicated there were no nursing note entries for Resident #1. During an interview on [DATE] at 1:57 p.m., NA D said she worked on [DATE] and was in the dining room during the lunch meal. She said around 12:30 p.m. RN C was feeding Resident #1 and she heard RN C call for RN A because something was off with Resident #1. She said RN A took Resident #1 out of the dining room and said they needed to lay him down. She said food was spilling out of Resident #1's mouth and she changed the resident's shirt. NA D said Resident #1's skin was clammy and cold, and he was breathing hard. NA D said Resident #1 did not look normal and his skin was not normally cool and clammy. NA D said she told RN A and RN A said she was going to administer a breathing treatment and the resident just got overheated. NA D said she and RN A transferred the resident to his bed and she left the room while RN A stayed in the room with Resident #1. She said she notified the oncoming CNAs to keep an eye on Resident #1 because he did not look good. During an interview on [DATE] at 2:23 p.m., CNA E said she worked on [DATE] from 2:00 p.m. to 10:00 p.m. on Resident #1's hall. She said she entered Resident #1's room around 3:00 p.m. She said he was lying in his bed and he was wearing a breathing treatment face mask and the resident opened his eyes when she walked into the room. CNA E said Resident #1 did not look good. She said Resident #1's skin appeared slightly gray and his skin felt cool and clammy. She said his forehead was reddish pink and felt warm. She said that was not normal for him. CNA E said RN A was in the hall and she notified RN A about Resident #1's skin and told her he did not look right. She said RN A said Resident #1 had overheated. CNA E said RN A did not go into Resident #1's room. She said around 4:00 p.m., she and CNA H went into Resident #1's room and Resident #1's skin was gray, and his skin was cool and clammy. She said Resident #1 looked like he was having trouble breathing. She said she found RN A and reported Resident #1's condition and asked RN A if she would look at him. She said RN A did not go into the room and check on Resident #1. She said RN A told her to put Resident #1 in his geriatric chair for dinner. CNA E said she, CNA H, and NA F went to Resident #1's room around 4:20 p.m. and Resident #1's skin was gray, cold, and clammy. She said the resident's hands were purple. She said Resident #1's legs had blue veins and the resident was taking deep breaths. She said it took all 3 of them to transfer Resident #1 to his geriatric chair. She said they looked for RN A when they got into the hallway, but she was outside smoking. CNA E said she saw RN B and asked her to assess Resident #1. She said RN B assessed the resident and said to lay him back down and they would call 911. She said RN A walked back in from outside and RN B told RN A Resident #1 was going to the hospital. During an interview on [DATE] at 12:26 p.m., NA F said she worked on [DATE]. She said about 4:00 p.m. she went to Resident #1's room and he did not look himself and the resident said he was not feeling good. She said Resident #1 looked like he was struggling to breath. NA F said she reported her concerns to RN A and RN A said she knew Resident #1 was not feeling good and she already given him a breathing treatment and to go ahead and get him up for dinner. She said she and 2 other staff went into the room to transfer Resident #1 to his geriatric chair and the resident's skin was gray in color, his skin was cold to touch, and his feet were freezing. She said it took 3 staff to transfer the resident which was unusual for the resident. She said the resident normally would assist during the transfer but Resident #1 was not assisting. NA F said they got Resident #1 transferred to his geriatric chair and went to look for RN A, but she was outside smoking. She said they saw RN B and notified RN B about Resident #1's condition. She said RN B assessed the resident and said he needed to be sent to the hospital. During an interview on [DATE] at 8:24 a.m., NA H said she worked on [DATE] from 2:00 p.m. to 10:00 p.m. and it was the first day she worked with Resident #1. She said she entered Resident #1's room about 4:00 p.m. and Resident #1 was lying in his bed. She said the resident looked very pale, but his forehead was red. She said Resident #1 looked like he was holding his breath and then he would gasp for air. She said Resident #1's eyes were open, but he was not able to answer questions. She said she called for CNA E. NA H said CNA E came to the room and saw Resident #1. She said CNA E found RN A and told RN A that Resident #1 was not looking good and he was struggling to breath. NA H said RN A did not check on Resident #1 and told CNA E to get Resident #1 up in his geriatric chair because it was almost time for dinner. NA H said they transferred Resident #1 to his geriatric chair and then saw RN B in the hall. She said CNA E asked RN B to assess Resident #1. NA H said RN B assessed Resident #1 and instructed them to put Resident #1 back in his bed and they would call 911. During an interview on [DATE] at 1:28 p.m., RN B said she was the weekend supervisor and at 4:50 p.m., CNA E asked her if she would look at Resident #1 because he did not look right. RN B said she asked CNA E if she notified RN A about her concerns and CNA E said she already notified RN A. RN B said from 4 feet away she could tell Resident #1 was struggling to breathe. She said his pulse was 132 and his respiration rate was 32 breaths a minute. She said Resident #1's hands were cool and mottled. She said she told the CNAs to transfer the resident back into the bed and put a gown on him. She said Resident #1's legs were mottled from the knees down. She said the resident's oxygen saturation was 91% and she applied oxygen. She said Resident #1 nodded when she told him he was going to the hospital. She said when they found RN A, she told RN A that Resident #1 needed to go to the hospital for a change of condition and told RN A she needed to call 911 and gather Resident #1's paperwork. She said RN A said Resident #1 was hot earlier and she gave him a breathing treatment. RN B said she told RN A the resident was not wheezing, and he was having heart and circulation issues. RN B said RN A was the only staff member that said Resident #1 was hot. She said EMS arrived and transferred the resident to the hospital. During an interview on [DATE] at 1:02 p.m., the NP said he was notified on [DATE] at 5:24 p.m. by RN A that Resident #1 had a pulse of 132, oxygen saturation of 91%, and blue hands. He said he gave the order to send the resident to the hospital. He said he was not notified about Resident #1's increased breathing earlier in the day. The NP said he expected nurses to complete a full assessment and notify him of any changes of condition. He said he was on-call on [DATE] and had no issues with sending residents to the hospital for evaluation. During an interview on [DATE] at 3:31 p.m., the administrator said he expected nurses to immediately assess a resident if they noticed a change of condition or if they were notified about a change of condition. The administrator said the nurses should document the change of condition, assessment, and interventions that were completed in the resident record. A policy revised on [DATE] indicated .the nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .the nurse will monitor and reassess the resident's status and response to interventions .the nurse will document all attempts to contact the physician, all attempts to notify the family, the physician's response, the physician's orders [REDACTED]. The administrator and DON were notified on [DATE] at 11:18 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on [DATE] at 11:27 a.m. The facility's Plan of Removal was accepted on [DATE] at 1:54 p.m. and included: Plan of Removal Problem: Assessment of resident after change in condition Interventions: o Employment of RN assigned to resident's care has been terminated. o Effective immediately, every Resident will be assessed for Change of Condition. These assessments will be completed by [DATE] @ 5:00pm. o Direct Care Staff will continue to use the Stop and Watch program to report changes of condition to charge nurse or an appropriate member of Nursing Management. o The following in-services were initiated by the DON, ADON and regional nurse on [DATE]. These in-services will be completed on [DATE] by 5:00pm. Any staff member not present or in-serviced on [DATE], will not be allowed to assume their duties until in-serviced. o Licensed Nurses * Immediate and correctly assessing a resident when a change of condition has been identified / reported. * Reporting changes of condition to the physician or nurse practitioner. o Non-licensed nursing staff * Reporting changes in a resident's condition to a nurse immediately using Stop and Watch. After entering the change in the point of care, the non-licensed staff member is to verbally report the change to the nurse. * If nurse does not respond immediately, Director of Nursing or designee will be notified Immediately. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 9:21 a.m., the administrator said in-servicing was initiated with staff on [DATE] and no staff would be allowed to return to duty until they were in-serviced. During an interview on [DATE] at 9:38 a.m., the DON said all residents were assessed for changes in condition on [DATE] and 2 residents were noted with a change in condition. The DON said the residents' physician and hospice provider were notified of the change and interventions were put in place. Five CNAs, 3 NAs and 1 MA (6 a.m. to 2 p.m., 7 a.m. to 3 p.m., 11 a.m. to 7 p.m., 2 p.m. to 10 p.m. shift, and 10 p.m. to 6 a.m. shift) said they were in-serviced on changes of condition. They were able to identify examples of changes of condition and said they would report any changes of condition resident's charge nurse. They said if the resident's charge nurse did not immediately assess the resident, they would notify the DON. They said they would also document the change of condition using the stop and watch tool under the alert tab in the point of care charting system. Seven nurses (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and 10 p.m. to 6 a.m.) said they were in-serviced on changes of condition. They were able to identify examples of changes of condition. They said they would immediately assess a resident if they noticed a change of condition or if staff notified them of a change of condition. They said if a resident presented with changes of condition, they would assess the resident and call the NP and responsible party. They said they would document any changes of condition in the resident's clinical record and interventions that were put into place. Change of condition assessments dated [DATE] for 102 residents were reviewed. There was evidence of changes of condition for 2 residents and assessments and interventions were documented in the resident record including notification of the NP and hospice provider. On [DATE] at 1:05 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at actual harm at a pattern of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview, and record review, the facility failed to provide services as outlined by the comprehensive care plan that meet professional standards of quality for 1 of 8 residents reviewed for ADL assistance. (Resident #1) The facility did not implement the care plan for Resident #1 regarding transfers. CNA A and B transferred Resident #1 from bed to wheelchair without using the Hoyer lift as indicated in the plan of care. Resident #1 knees buckled during the transfer, an x-ray indicated Resident #1 had an acute [MEDICAL CONDITION] femur (area of the leg just above the knee joint) with displacement (degree and direction) and soft tissue swelling and effusion, osteopenia, knee joint space narrowing. This failure could place residents who required the use of a mechanical lift for transfers at risk of injury. Findings included: A face sheet dated 07/08/19 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. An MDS dated [DATE] indicated Resident #1 was non-ambulatory and used a wheelchair as a mobility device. Resident #1 required extensive assistance with ADLs and required two-person physical assist with transfers. Resident #1 had severely impaired cognition. The MDS did not address a Hoyer lift or weight bearing. An undated care plan indicated Resident #1 was at risk for falls and required a mechanical lift with two staff members to assist with transfers. Resident #1 had an activities of daily living self-care performance deficit related to generalized weakness and required a Hoyer lift with two staff members assist with transfers and she used a wheelchair. An incident report dated 07/07/19 at 9:00 p.m., indicated a CNA reported swelling to Resident #1's right knee and the resident was unable to give a statement as to what happened to cause the swelling to knee. A CNA reported her knees buckled during a morning transfer from bed to wheelchair. An x-ray dated 07/07/19 indicated Resident #1 had an acute [MEDICAL CONDITION] thigh with displacement and soft tissue swelling, osteopenia, knee joint space narrowing. A provider investigation report dated 07/08/19 by the DON indicated on 7/7/19 CNA A and CNA B transferred Resident #1 from the bed when Resident #1's legs buckled. CNAs A and B lifted Resident #1 into her wheelchair using her pants for support. Resident #1 did not go to the ground. Resident #1 was care planned for mechanical (Hoyer) lift transfers with two persons assist. Resident #1's right knee was noted to have [MEDICAL CONDITION] (swelling) later in the day. An X-ray revealed a fracture to the distal femur. A witness statement dated 07/07/19 by CNA B indicated she assisted CNA A getting Resident #1 up around 6:30 a.m. CNA B said they got her out of the bed, her feet buckled, and they grabbed her by her pants for support and put her in chair. The provider investigation report findings were confirmed. A disciplinary report dated 07/18/19 indicated CNA A and CNA B failed to adhere to their job duties/responsibilities and failed to properly transfer a resident per care plan instructions two-person Hoyer lift. During an interview on 12/03/19 at 9:16 a.m., the DON said Resident #1 could not walk and required a two-person Hoyer lift when transferred. The DON said CNA A and B transferred Resident #1 from her bed to her wheelchair without using the Hoyer lift. She said when CNAs A and B transferred Resident #1 her legs gave out when she stood up and they assisted Resident #1 to her wheelchair by grabbing her pants. The DON said a CNA who worked the following shift noted swelling to Resident #1's right knee and reported it to the nurse. The DON said Resident #1 was sent to the hospital and diagnosed with [REDACTED].#1's care plan indicated she required a two-person Hoyer lift when the injury occurred. The DON said CNA A and CNA B did not follow the care plan when they transferred Resident #1. The DON said Resident #1 would not have been injured if the care plan was followed. The DON said following the incident the facility staff were in-serviced on operating a Hoyer lift, following the residents care plan to prevent injury and how and where to access a residents care plan. The DON said CNA B no longer worked in the facility. During an interview on 12/03/19 at 12:05 p.m., CNA A said Resident #1 could not walk and required two-person assistance when transferred. CNA A said she was in a hurry to get all her residents dressed and out of bed for the day and asked CNA B to assist her with Resident #1. CNA A said CNA B assisted her when they transferred Resident #1 from her bed to her wheelchair without using a Hoyer lift. CNA A said when they transferred Resident #1 her legs gave out when she stood up and they assisted Resident #1 to her wheelchair by grabbing her pants. CNA A said Resident #1 did not complain of any pain after the transfer or during her shift. CNA A said after her shift Resident #1 was sent to the hospital and diagnosed with [REDACTED].#1 without using a Hoyer lift and she should have checked Resident #1's care plan to see what assistance was needed. CNA A said she provided care for Resident #1 before the incident and she did not know Resident #1 required a two-person Hoyer lift when transferred. CNA A said a care plan was used to promote safety when providing care to a resident. CNA A said she was trained on how to operate a Hoyer lift prior to the incident and she had access to Resident #1's care plan before the transfer. CNA A said she and CNA B did not follow Resident #1's care plan when they transferred her and Resident #1 would not have been injured if the care plan was followed. CNA A said following the incident she was in-serviced on operating a Hoyer lift, following a residents care plan to prevent injury and how and where to access a residents care plan. An in-service dated 07/09/19 indicated staff were in-serviced on operating a Hoyer lift, following a residents care plan to prevent injury and how and where to access a residents care plan. The CNA job duties dated 2010 from the human resources manual indicated a non-exhaustive criterion that relates to the job of a CNA, Knowledge Base .Ability to comply with company and departmental safety policies and procedures .Ambulate and transfer residents within patient care policy guidelines. An undated comprehensive care planning policy indicated the facility will develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives . The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. An undated statement of resident rights indicated you have the right live in safe, decent, and clean conditions. Be free from abuse, neglect and exploitation .receive all care necessary to have the highest possible level of health. An in-service dated 07/09/19 indicated staff were in-serviced on operating a Hoyer lift, following a residents care plan to prevent injury and how and where to access a residents care plan.

Based on interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents was provided for 1 of 8 residents reviewed for accidents. (Resident #1) The facility did not implement the care plan for Resident #1 regarding transfers. CNA A and B transferred Resident #1 from bed to wheelchair without using the Hoyer lift as indicated in the plan of care and Resident #1 knees buckled during the transfer. An x-ray indicated Resident #1 had an acute [MEDICAL CONDITION] femur (area of the leg just above the knee joint) with displacement (degree and direction) and soft tissue swelling and effusion (an escape of fluid into a body cavity), osteopenia, knee joint space narrowing. This failure could place residents who required the use of a mechanical lift for transfers at risk of injury. Findings included: A face sheet dated 07/08/19 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. An MDS dated [DATE] indicated Resident #1 was non-ambulatory and used a wheelchair as a mobility device. Resident #1 required extensive assistance with ADLs and required two-person physical assist with transfers. Resident #1 had severely impaired cognition. The MDS did not address a Hoyer lift or weight bearing. An undated care plan indicated Resident #1 was at risk for falls and required a mechanical lift with two staff members to assist with transfers. Resident #1 had an activities of daily living self-care performance deficit related to generalized weakness and required a Hoyer lift with two staff members assist with transfers and she used a wheelchair. An incident report dated 07/07/19 at 9:00 p.m., indicated a CNA reported swelling to Resident #1's right knee and the resident was unable to give a statement as to what happened to cause the swelling to knee. A CNA reported her knees buckled during a morning transfer from bed to wheelchair. An x-ray dated 07/07/19 indicated Resident #1 had an acute [MEDICAL CONDITION] thigh with displacement and soft tissue swelling, osteopenia, knee joint space narrowing. A provider investigation report dated 07/08/19 by the DON indicated on 7/7/19 CNA A and CNA B transferred Resident #1 from the bed when Resident #1's legs buckled. CNAs A and B lifted Resident #1 into her wheelchair using her pants for support. Resident #1 did not go to the ground. Resident #1 was care planned for mechanical (Hoyer) lift transfers with two persons assist. Resident #1's right knee was noted to have [MEDICAL CONDITION] (swelling) later in the day. An X-ray revealed a fracture to the distal femur. A witness statement dated 07/07/19 by CNA B indicated she assisted CNA A getting Resident #1 up around 6:30 a.m. CNA B said they got her out of the bed, her feet buckled, and they grabbed her by her pants for support and put her in chair. The provider investigation report findings were confirmed. A disciplinary report dated 07/18/19 indicated CNA A and CNA B failed to adhere to their job duties/responsibilities and failed to properly transfer a resident per care plan instructions two-person Hoyer lift. During an interview on 12/03/19 at 9:16 a.m., the DON said Resident #1 could not walk and required a two-person Hoyer lift when transferred. The DON said CNA A and B transferred Resident #1 from her bed to her wheelchair without using the Hoyer lift. She said when CNAs A and B transferred Resident #1 her legs gave out when she stood up and they assisted Resident #1 to her wheelchair by grabbing her pants. The DON said a CNA who worked the following shift noted swelling to Resident #1's right knee and reported it to the nurse. The DON said Resident #1 was sent to the hospital and diagnosed with [REDACTED].#1's care plan indicated she required a two-person Hoyer lift when the injury occurred. The DON said CNA A and CNA B did not follow the care plan when they transferred Resident #1. The DON said Resident #1 would not have been injured if the care plan was followed. The DON said following the incident the facility staff were in-serviced on operating a Hoyer lift, following the residents care plan to prevent injury and how and where to access a residents care plan. The DON said CNA B no longer worked in the facility. During an interview on 12/03/19 at 12:05 p.m., CNA A said Resident #1 could not walk and required two-person assistance when transferred. CNA A said she was in a hurry to get all her residents dressed and out of bed for the day and asked CNA B to assist her with Resident #1. CNA A said CNA B assisted her when they transferred Resident #1 from her bed to her wheelchair without using a Hoyer lift. CNA A said when they transferred Resident #1 her legs gave out when she stood up and they assisted Resident #1 to her wheelchair by grabbing her pants. CNA A said Resident #1 did not complain of any pain after the transfer or during her shift. CNA A said after her shift Resident #1 was sent to the hospital and diagnosed with [REDACTED].#1 without using a Hoyer lift and she should have checked Resident #1's care plan to see what assistance was needed. CNA A said she provided care for Resident #1 before the incident and she did not know Resident #1 required a two-person Hoyer lift when transferred. CNA A said a care plan was used to promote safety when providing care to a resident. CNA A said she was trained on how to operate a Hoyer lift prior to the incident and she had access to Resident #1's care plan before the transfer. CNA A said she and CNA B did not follow Resident #1's care plan when they transferred her and Resident #1 would not have been injured if the care plan was followed. CNA A said following the incident she was in-serviced on operating a Hoyer lift, following a residents care plan to prevent injury and how and where to access a residents care plan. The CNA job duties dated 2010 from the human resources manual indicated a non-exhaustive criterion that relates to the job of a CNA, Knowledge Base .Ability to comply with company and departmental safety policies and procedures .Ambulate and transfer residents within patient care policy guidelines. An undated comprehensive care planning policy indicated the facility will develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives . The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. An undated statement of resident rights indicated you have the right live in safe, decent, and clean conditions. Be free from abuse, neglect and exploitation .receive all care necessary to have the highest possible level of health. An in-service dated 07/09/19 indicated staff were in-serviced on operating a Hoyer lift, following a residents care plan to prevent injury and how and where to access a residents care plan.

Based on interview and record review, the facility failed to provide adequate supervision and assistance to residents to prevent accidents for 1 of 10 residents reviewed for accidents. (Resident #1) CNA A and CNA B did not transfer Resident #1 from the chair to the bed properly while using a mechanical lift; the resident was placed too close to the footboard. The staff caught the resident's foot on the lift, which resulted in a fracture to the resident's left hip. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who required assistance with transfers at risk of further injury. Findings included: An undated face sheet indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 required at least two people to physical assist with transfers. Resident #1 had functional limitations to both legs. A care plan dated 01/16/19 indicated Resident #1 had [MEDICAL CONDITION] and was at risk for fractures and had a history of [REDACTED].#1's goal was to remain free of injuries or complications related to [MEDICAL CONDITION]. Resident #1 required a lift with two staff for assistance for all transfers. The care plan for Resident #1 indicated caregivers were to be educated on safety measures to reduce the resident's risk of falls. A nursing note written by LVN C, dated 02/04/19 at 8:00 p.m., indicated Resident #1 was sitting up in a chair, and the CNAs used the mechanical lift to get the resident out of the chair. Resident #1's foot was in the way of the pump when one CNA lifted the resident's foot up, causing a loud pop. A CNA immediately got LVN C. Resident #1 was still in the chair when LVN C entered the room and examined the resident. The note indicated the resident did not complain of any pain. The note indicated Resident #1 was on the bed and turned on her right side, and the resident started screaming of pain. The note indicated hospice and the DON were notified, and she obtained an order for [REDACTED]. An x-ray report dated 02/04/19 indicated Resident #1 had a (new) left acute femoral neck fracture and a right proximal femur (hip) fracture of an indeterminate age. During an interview on 06/24/19 at 2:51 p.m., CNA A said she and CNA B were transferring Resident #1 from her chair to her bed on 02/04/19 using a mechanical lift. She said it was difficult to work around Resident #1's chair because it would not fold up, and it was large. She said she and CNA B got Resident #1 laid down on the bed, but the resident was too close to the footboard. She said she lifted Resident #1's left leg and heard a pop. She said the resident cried out, so CNA B got the nurse. During an interview on 06/25/19 at 2:18 p.m., CNA B said on 02/04/19 she and CNA A were transferring Resident #1 from her chair to her bed using a mechanical lift. She said she was standing behind the resident and indicated she was standing near the resident's head while the resident was prone in the chair, which was still extended. She said CNA A pushed the lift under the resident's chair perpendicular to the chair and bed. She said she noticed Resident #1's left foot was stuck under a bar on the lift, so she told CNA A to stop lifting the resident. She said CNA A put her hand under Resident #1's left heel and pulled up on it. She said before she could tell CNA A not to pull on the resident's foot, the resident started hollering, so she ran and got the nurse. A witness statement dated 2/4/19 completed by CNA B indicated CNA A was pumping the handle on the lift, when CNA B told CNA A to watch the resident's foot, and when CNA A attempted to move Resident #1's foot out of the way, the resident shouted no more. The witness statement indicated CNA A told Resident #1 they needed to get her foot out of the way so they could get her out of the chair, and when CNA A lifted the resident's foot, it made a loud pop. During an interview on 06/25/19 at 2:09 p.m., LVN C said on 02/04/19 an aide told her Resident #1's leg popped while she and another aide were putting the resident back in bed using the mechanical lift, and now the resident was complaining of pain. LVN C said when she entered the room, Resident #1 was lying on the bed. She said she assessed the resident and notified hospice of the situation. She said she was told by CNA A and CNA B that Resident #1's leg popped during the transfer from the chair to the bed. LVN C said she was not told Resident #1's foot got stuck during the transfer. During observations on 6/24/19 from 1:40 p.m. to 2:45 p.m., six CNAs, including CNA A and CNA B transferred three different residents using the lift without incident. An in-service training report dated 2/21/19 indicated 31 staff were in-serviced on proper use of the lift. A hoyer lift competency checklist dated 9/30/18 indicated CNA A demonstrated competency in all skills on 9/30/18, and a checklist dated 9/29/19 indicated CNA B demonstrated competency in the hoyer lift skills, with a follow up competency demonstration on 2/6/19, following the incident. The competency checklist included the instruction (#12) when lowering lift, monitor the location of resident's feet and arms to prevent injury. An undated policy and procedure for mechanical or hydraulic lift indicated once the resident was in the sling and straps were connected, the lift should only be raised to the point where the resident's body clears the chair . a lifting partner can help support and guide the resident's body while you roll the lift so that the resident is positioned over the chair or wheelchair .having another person to help to support and guide the resident promotes safety during the transfer and lessens the chance of injury.