Every finding on record at Lakeshore Village Nursing and Rehabilitation

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 1 of 5 residents (Resident #1) reviewed for resident rights.The facility failed to ensure Residents #1's call light was assessable while Resident # 1 was in bed.This failure could affect residents who needed assistance with ADL's needs not being met. Findings included:Record review of Resident #1's admission record dated 08/21/2026 documented a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included: unspecified injury C4 level of cervical spinal cord subsequent encounter(damage at the fifth neck vertebra where the exact physical nature of injury is not yet detailed), contracture right hand(a benign condition where the connective tissues beneath the palm's skin thickens and forms tight cords that pull the fingers toward the palm), quadriplegia C1-C4 incomplete(damage to the top part of the neck's spinal cord preserves some movement or feeling below the neck, through all limbs and the torso are affected), and hyperlipidemia unspecified(high levels of fats in blood).Record review of Resident #1's care plan dated 07/24/2026 revealed Resident # 1 was care planned for impaired physical functioning r/t debility and weakness with intervention of partial to substantial assist lifting to sitting on side of bed.Record review of Resident #1's admission MDS assessment, dated 06/30/2026, revealed the resident had a BIMS score of 12 indicating the resident was moderate cognitive impaired. The MDS also revealed Resident #1 picking up an object was not attempted and the resident did not perform this activity prior to the current illness or injury. Resident #1 required supervison or touching assistance with eating and oral hygiene. Resident #1 required substantial maximal assistance with toileting hygiene, showering/bathing self, and upper/lower body dressing.Observation on 08/21/2026 at 11:25 AM, revealed Resident #1 could be heard yelling from his room on hall 700. Resident #1 was heard saying he could not get any help around this place and that he wanted to get out there. Resident # 1 was observed lying flat on his back and the blanket and sheet entwined with the call light button at the end of the bed where Resident # 1 was not able to reach.During an interview on 08/21/2026 at 11:30 AM, Resident # 1 stated that he was safe and seem to not be able to get any help around here. Resident #1 stated that he was yelling out for someone to come and pull the covers back on him because he had gotten cold. Resident #1 stated he had been waiting for about 30 minutes and yelling out for someone to come. Resident # 1 stated he did not know where his call light was and he stated it was always not in reach or not found. Resident # 1 stated he would normally just wait for staff to finally come in to assist him.During an interview on 08/21/2026 at 1:03 PM, CNA A stated that she had just left Resident #1's room before surveyor came down hall 700. CNA A stated she had changed Resident #1's brief and he wanted her to pull the covers back. Resident #1 stated he did not know the call light was tangled in the blanket and sheet. CNA A stated she failed to look to see if the call light was placed where Resident # 1 could reach. CNA A stated it was expected for her to check and make sure the call light was in place. CNA A stated if the call light was not in reach the residents would not get the help that they need.During an interview and observation on 08/21/2026 at 1:37 PM, LVN B stated that Resident #1 does not like the blanket on and staff had to place the blanket on and off Resident #1. LVN B observed with the state surveyor that Resident #1's call light was tangled with the blanket and sheet. LVN B observed the call light was not in reach of Resident #1. LVN B stated it was expected for CNA A to have checked to make sure Resident #1's call light was in place before she had left the room. LVN B stated when the call light was not in reach of Resident # 1, he was not able to get assistance.During an interview on 08/21/2026 at 3:55 PM, the DON stated it was expected for CNA A to have placed Resident #1's call light in reach. The DON stated it was expected the for the call light where the resident wants it to prevent tangling. The DON stated when the call lights were not in reach of Resident #1 he did not receive the help that he needed at that time.During an interview on 08/21/2026 at 4:10 PM, the ADM stated it was expected for the call light to be in reach where residents prefer. The ADM stated that it was CNA A's responsibility to make sure the call was in place. The ADM stated when the call light was not in place, resident's needs would not have been met.Review of the facility's Answering the Call Light policy, dated 2001, reflected, Purpose: The purpose of this procedure is to ensure timely responses to the residents' requests and needs.General Guidelines1. Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident.2. Ask the resident to return the demonstration.3. Explain to the resident that a call system is also located in his/her bathroom.4. Be sure that the call light is pulled in and functioning at all times.5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.6. Report all defective call lights to the nurse supervisor promptly.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 2 of 5 residents (Resident #1 and Resident #4) reviewed for PASARR Level I screenings.1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #1 and Resident #4. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis PTSD (post-traumatic stress disorder) with an onset was present upon Resident #1 and Resident #4's admission.2. The facility did not complete a 1012 form to update Resident #1 and Resident #4's PASARR Level 1 with the new diagnosis.This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.Findings included:Resident #1Record review of Resident #1's face sheet indicated a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of schizophrenia, anxiety disorder, and need for assistance mobility.Record review of Resident #1's MDS record dated 04/10/2026 did not have diagnosis of schizophrenia triggered at that time.Record review of Resident #1's care plan record indicated Resident #1 had prescription for antidepressants, antipsychotics, antianxiety related to anxiety and schizophrenia.Record review of Resident #1's level 1 PASARR dated 03/12/2026 indicated that Resident #1 had no evidence of a primary diagnosis for this individual, individual had a mental illness, an intellectual disability and/or evidence that this individual has a developmental disability.Resident #4Record review of Resident #4's face sheet, dated 04/21/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Post-Traumatic Stress Disorder (a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock, typically involving disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and to the outside world), schizoaffective disorder, depressive type (a chronic mental health condition that combines symptoms of schizophrenia, such as hallucinations and delusions, with mood disorder symptoms, including depression or mania), auditory hallucinations (are false perceptions of sound, where an individual hears voices or noises that are not present in the environment), major depressive disorder of brain, not elsewhere classified (a psychiatric diagnosis used when a patient has symptoms consistent with major depression but does not fit into a more specific category), altered mental status, unspecified (a change in cognitive function, awareness, or consciousness without a clearly identified cause).Record review of Resident #4's quarterly MDS assessment, dated 3/17/26, reflected he had a BIMS score of 14, which indicated intact cognition. Resident #4. The MDS assessment reflected Resident #4 required setup or clean-up assistance with eating, required supervision or touching assistance for toileting, showering, and personal hygiene.Record review of Resident #4's PASARR Level 1 Screening, dated 12/09/2025, reflected that in Section C Mental Illness was marked as no, which indicated Resident #4 did not have a mental illness.Record review of Resident #4's care plan dated 01/09/26 reflected Resident #4 had a diagnosis of post-traumatic stress disorder and was at risk for behaviors associated with PTSD.Goal: Resident will feel more peaceful and at ease with improved quality of life.Interventions included Administer physician prescribed anxiolytics and monitor for side effects. Psych Referral as needed to evaluate and follow in house or outpatient.An interview conducted on 04/22/2026 at 10:26AM with MDS A stated they had worked at the facility for 3 years, in MDS role. MDS A stated that MDS was responsible for making sure that PASARR was completed correctly. MDS A stated that the purpose of a completed and accurate PASARR was to make sure that the resident was eligible for PASARR services and should be provided with the services as desired. MDS A stated PASARR should be completed before admission or within 48 hours of admission into the facility. MDS A stated she would ensure that the PASARR was accurate once the resident admitted to the facility. MDS A stated that diagnoses of schizophrenia, bipolar, major depressive disorder, severe anxiety, and PTSD would trigger a positive level 1 PASARR. She stated if a resident had one of those diagnoses, their PASARR status would be positive. MDS A stated if the PASARR was positive, the facility would refer to the resident for a level 2 PASARR screening. She stated if the resident had an inaccurate PASARR the resident may not get the services they need right away. MDS A stated Resident #1 had a negative PASARR level 1. She stated that because Resident #1 had a diagnosis of schizophrenia, his PASARR should have been positive, not negative.An interview conducted on 04/22/2026 at 12:10PM with the DON stated they had worked at the facility for 5 years. The DON stated MDS department was responsible for ensuring the PASARR was completed accurately. She stated that the purpose of an accurate PASARR was to ensure that the services are provided to the residents who are eligible based off their diagnosis. The DON stated that PASARR should be completed upon admission and/or before admission. She stated that diagnosis would trigger a positive PASARR but could not indicate which diagnosis. She stated that the residents would not receive their eligible services if the PASARR was incorrect.An interview conducted on 04/22/2026 at 12:41PM with the ADM stated he had worked at the facility for 9 years. The ADM stated that the MDS team was responsible for accurate PASARR's. He stated that the purpose of an accurate PASARR was to organize services for PASARR positive residents. He stated that the PASARR should be completed when they enter the facility and/or before. The ADM stated if a resident had diagnosis criteria, then the PASARR would be positive. He stated that if the PASARR was positive then they would communicate that to the PASARR nurse. He stated that a lot of mental health issues like major depressive disorder would indicate a positive PASARR. He stated that he believes a resident would have a positive PASARR if they had diagnoses like major depressive disorder. The ADM stated that if the PASARR was inaccurate, then the residents could have missed services that they are eligible for. The ADM does not know if Resident #1's diagnosis of schizophrenia, would indicate a positive level 1 PASARR. Record review of facility provided policy titled Resident Assessment-Coordination with PASARR program dated 05/05/2025 indicated the following:The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admissioni. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. The facility designee shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include:a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

Based on interviews, record reviews, and observations, the facility failed to ensure food was stored in accordance with professional standards for food safety. The facility failed to ensure food was labeled and dated correctly in the refrigerator and freezer on 04/20/26. This failure could place the residents at risk of foodborne illnesses.Findings include: Observation on 04/20/26 at 9:02 AM of the kitchen revealed the following:An opened package of small bite sized oval shaped pieces, with a crumbly breaded coating and a pale golden color that was in the freezer, did not have a label, a delivery date, an opened date, or a disposal date on it.An opened package of provolone cheese in the refrigerator did not have a delivery date or an opened date. However, there was a used by date of 03/11/26.An opened package of French toast in the freezer had a delivery date of 03/10/26, opened date of 04/13/26, but did not have a disposal date. Interview on 04/20/26 at 10:48 AM with DM revealed that food in the refrigerator and freezer should have 3 dates on them: the date the food was delivered to the facility, the date the food was opened, and a disposal date. She also stated that all food items should be labeled. DM stated the disposal date was between 3 - 5 days from the opened date, depending on the product. She stated this was important so that staff would be able to determine what the product is and the product's freshness. She stated she was the one who checked the food when it was delivered and was responsible for ensuring that the delivery date was written on each package. She stated she did not know why each package was not labeled and did not have a delivery date on it as she normally tried to make sure it was done. She advised staff to be trained in labeling and dating food. She stated that she would follow up with kitchen staff to ensure that all items in the refrigerator and freezer were labeled correctly, had a delivery date, an open date, and disposal date on them. She stated that they have a food dating policy. Interview on 04/22/26 at 8:34 AM with CK1 revealed the food in the refrigerator and freezer should be labeled and have 3 dates on them: the date the food was delivered to the facility, the date the food was opened, and a disposal date. He stated the disposal date was between 3 - 5 days from the open date, depending on the product. He stated this was important because staff would know what they got out of the refrigerator and freezer and to keep the residents from getting sick with foodborne illnesses. He stated the DM was the one who checked the food when it was delivered and the rest of the kitchen staff was her backup when DM was not there. He stated that the facility had a food dating policy. Interview on 04/22/26 at 8:42 AM with the ADM revealed the facility had a food storage and dating policy. He stated the DM was responsible for ensuring that the policy was followed. He stated all food should be labeled and dated when it was delivered to the facility, but he did not mention there should be an open date or a disposal date on them. He stated it was important to ensure the dates were on the food packages to ensure residents did not get sick with foodborne illnesses. Record review on 04/20/26 of the food receiving and storage policy revised 10/2017, revealed the following: Policy Statement:Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation:8. All food stored in the refrigerator or freezer will be covered, labeled, and dated ( use by date).

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #132, Resident #120, and Resident #58) reviewed for infection control. LVN A failed to disinfect the blood pressure cuff between residents (R#58, R#132, R#120) while performing medication administration. This failure place residents at risk for cross contamination and the development of infections.Findings include:In an observation of medication administration on 4/21/2026 at 8:00 AM LVN A utilized the blood pressure cuff on Resident #58, Resident #132, and Resident #120 and failed to disinfect the blood pressure cuff between residents.In an interview on 4/21/2026 at 9:02 AM LVN A stated that she was frequently in-serviced on infection control. She stated that it was policy to cleanse the blood pressure cuff with each use between residents. She stated that she has been working in the facility for 20 years and knows she should have wiped the blood pressure cuff off with the sanitizing wipe between each resident. She stated that by not cleansing the blood pressure cuff between residents she could potentially spread germs and cause residents to get sick. She did not have a reason why she failed to clean the blood pressure cuff.In an interview on 4/22/2026 at 10:38 AM with DON she stated she frequently services the nursing staff on infection control. She stated that the policy states that reusable medical equipment was cleansed between each resident. She stated that if items are not cleansed between each resident, they can spread infection. She stated it was her expectation that her staff disinfect items between each resident.In an interview on 4/22/2026 at 12:42 PM with ADM he stated he has been the Administrator for the facility for 9 years. He stated that the staff are frequently in-serviced on infection control. He stated the staff should cleanse reusable equipment such as a blood pressure cuff between residents and that is his expectation. He stated that if reusable equipment is not cleansed between each resident, it could pass infection if they had something and it would be just grossness.Review of facility policy titled, Infection Prevention and Control Program, dated 4/11/2025 which stated, This facility has established and maintains infection prevention and control program to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy explanation and compliance guideline #10-Equipment protocol stated, a. All reusable items and equipment requiring special cleaning, disinfecting, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment., c. Reusable items potentially contaminated with infectious materials shall be cleaned and disinfected as per manufacturer guidelines by staff, d. Staff will decontaminate equipment with a germicidal detergent prior to storing for reuse.

Based on observation and interviews the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 1 days reviewed (4/21/2026) reviewed for nurse staffing posting. The facility failed to post accurate daily staffing information on 4/21/2026. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included:During an observation on 4/21/2026 at 12:00 PM, the daily staffing census information was posted on the wall in the entrance area dated 4/20/2026. During an interview on 4/21/2026 at 12:11 p.m., the DON stated it was her job to post the daily staffing. She stated nobody would know what the staffing would be. During an interview on 4/21/2026 at 12:17 p.m., the ADM stated it was the DON job to post the daily schedule, and the negative outcome was that staff would not know their hours and where to go. It was not posted but it was done. During an interview on 4/22/26, 12:10 pm ADON stated she was not responsible for posting the daily staffing. Staffing coordinator was responsible for posting the daily staffing. Family and residents will not know the staff to resident ratio. During an interview on 4/22/26, 12:14 pm Staff Coord stated the daily staffing posting was posted daily. She stated she was responsible for the daily sign-in sheet for the staff and where the staff will be assigned for that day. A negative outcome would be family, and residents would be confused of who is scheduled to work for the day. She stated HR was responsible for posting the daily staffing at the entrance of the building. ADM stated there was no policy regarding the daily posting of the schedule.

Based on interviews and record reviews, the facility failed to allow immediate access to residents by a state representative of HHSC in that:The facility's Administrator refused to allow a HHSC Employee to enter the facility on 03/03/2026 at 09:04 am to conduct a Priority One investigation.This failure placed all 123 residents at risk of potential harm due to a P1 investigation not being conducted to rule out immediacy.Findings included:Observation and interview on 03/03/2026 at about 08:55 am revealed a Representative of HHSC arrived at the facility and was told to wait for the Administrator in the lobby.Observation and interview on 03/03/2026 at about 09:04 am reflected the Administrator arrived in the facility's lobby and told the Representative of HHSC that, they're going to have to send somebody else. I filed a complaint against you. He further stated the resolution to his complaint was that the Representative of HHCS would not be allowed back in the building.Observation and interview on 03/03/2026 at about 9:47 am revealed that the HHSC Representative exited the facility's parking lot due not being allowed by the Administrator to conduct an investigation. Record review of census information provided by the facility revealed the census on 3/3/2026 was 123 residents.Record review of the Health and Safety Code Ch 242: Sec.242.043. Inspections reflected.(a) The commission or the commission representative may make any inspection, including an unannounced inspection or follow-up inspection, survey, or investigation that it considers necessary and may enter the premises of an institution at reasonable times to make an inspection, survey, or investigation in accordance with department rules.Review of Texas Health and Human Services Commission Provider Letter PL18-26, dated December 10, 2018, entitled Providing Access to Electronic Health Records revealed: The Texas Health and Human Services Commission (HHSC) is issuing this letter as a replacement of PL 18-10 to inform provider of the following updated information as it applies to all provider types. Providers must grant access to all electronic health records when requested by a surveyor.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision that could prevent accidents for 1 of 1 resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1's safety when OT was inattentive due to using her phone. This failure could place residents at risk of experiencing accidents and injuries.The findings included:Record review on 12/11/2025 of Resident #1s chart reflected he is a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of senile degeneration of brain, not elsewhere classified (age-related brain shrinkage and cognitive decline). Record review of Hearing Speech and Vision MDS dated [DATE] reflected Resident #1 had a BIMS of 11, indicating moderate cognitive impairment, with Moderately impaired - limited vision.Record review of the Care plan for Resident #1, dated 7/26/2023 and revised on 11/07/2025, reflected that Resident #1 has ADL Self Care Performance Deficits r/t Disease Process (COPD) & Fatigue. Interventions: Independent with: Walk 10/50/150 feet. Observation on 12/11/2025 at 11:45 a.m., OT was walking Resident #1 on the 500 Hall to the activity room. Resident #1 was walking using a cane. OT was behind Resident #1, pushing his wheelchair. While OT was pushing Resident #1's wheelchair, she was on her phone, looking at pictures and not paying attention to Resident #1In an interview on 12/11/2025 at 11:55 p.m., The OT stated she was walking with Resident #1 to the activity room. OT stated when she walked with a resident, she should not be on her phone. OT stated if Resident #1were to fall while on her phone, he could get seriously injured because she was not paying attention. OT stated that during resident care, staff are not permitted to use their phones. OT said she has received in-service training on not using phones during resident care. In an interview on 12/19/2025 at 2:06 PM, DON stated that when staff are providing resident care, they should focus on the resident and not on their phone. Staff should monitor the residents for safety to prevent injuries. DON mentioned that if staff do not monitor residents during care, a fall could occur, resulting in severe injury. DON also stated that she has not observed staff using their phones while providing resident care and that she has received in-service training on the facility's phone policy.In an interview on 12/19/2025 at 3:05 PM, ADM stated that staff may keep their phones on the floor for business purposes. ADM mentioned that staff should not have their phones while providing resident care. ADM explained that using phones during resident care could lead to falls and injuries. ADM stated that staff have received in-service training on the facility's phone policy. Record review of the Personal Cell Phone policy not dated indicated the following: It is the policy of this facility to provide quality care to our residents without interruption. This facility allows employees to use personal cell phones for professional communication while in the facility. Cell phones may be used by employees for personal use while on a scheduled break in break areas only.Record review of the facility Cell Phone Use During Patient Ambulation that was not dated indicated the following: Therapy Staff are not permitted to use personal cell phones while walking or providing mobility assistance to a patient. This includes texting, talking, browsing or any other phone-related activity. Cell phone use diverts attention and decreases situational awareness. Distraction increases the risk of patient falls, collisions, or loss of balance. Staff must be able to respond immediately to changes in patient gait, stability, and environment. Maintaining full attention demonstrates professionalism and supports high-quality patient care.

Based on interview and record review the facility failed to immediately notify Resident #1's Responsible Party and practitioners when there was a significant change the resident's physical status (a deterioration in health) for one of five residents (Resident #1) reviewed for resident rights. The facility failed to inform Resident #1's Responsible Party when he refused to eat or drink from dinner on 4/9/2025 to breakfast on 4/11/2025. The resident was sent to theER on [DATE] with altered mental status, high heart rate resulting in a diagnosis of Acute encephalopathy [altered brain function], Acute renal failure [decreased blood flow to the kidneys] and profound dehydration. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/8/2025 at 12:25 pm; the facility was notified and given an IJ template. While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for immediate harm to their health and safety related to lack of self-determination, decreased nutritional status and dehydration. of a lack of a dignified existence, self-determination and quality of life. Findings include: Record review of Resident 1#'s face sheet, dated 4/17/2025, reflected a [AGE] year-old male who was admitted to the NF on 4/9/2025. Resident #1 had diagnoses which included: Cerebral Infarction (stroke - when blood flow to the brain in blocked), Hypertension (high blood pressure), Neoplasm related pain (tumor related pain), Heart Disease, Ataxia (impaired coordination) and Myocardial Infarction (heart attack). Resident #1' s face sheet indicated a FM was his RP and his emergency contact #1. Record review of Resident #1's Care Plan, dated 4/23/2025, reflected the following problem made on 4/11/2025 after the resident was sent to the ER: Potential for alteration in nutrition r/t mechanically altered diet. Resident has been found to pocket food. The following interventions were listed for this problem: document meal intake in the clinical record, notify physician as needed. Record review of Resident #1's progress notes, dated 4/9/2025 - 4/11/2025, reflected no entries regarding refusal of nutrition or hydration, no entries that practitioners were notified of refusal of nutrition/hydration and no entries that RP was notified of refusal of nutrition/hydration by Resident #1. Record review of Resident #1's EMR reflected he had not been in the NF long enough to have a BIMS assessment completed for his cognition level. Record review of Resident #1's Admission Assessment, dated 4/9/2025 at 4:12 pm, by LVN-B, reflected he was drowsy/stuporous but oriented to person, place, time, situation and that his cognition was intact. Record review of Resident #1's POC, dated 4/23/25, reflected no nutrition/hydration entry for 4/9/2025 or 4/11/2025. There were 3 entries on 4/10/2025 at 8:00 AM, 12:00 PM and 5:00 PM in the 0-25% column . Record Review of Resident #1's vital signs revealed he had an admission weight of 134 pounds on 4/9/2025 at 3:35 pm. Vital signs taken between 4/10/2025 and 4/11/2025 revealed resident's oxygen saturation, blood pressure and respirations were within normal limits. Further review of Resident #1's pulse rate revealed pulse rate was elevated and outside of the normal limits (60-100 beats per minute) as follows: 4/10/2025, 10:11 am - 108 bpm (beats per minute) 4/10/2025, 11:57 am - 104 bpm 4/10/2025, 6:19 pm - 105 bpm 4/11/2025, 9:44 am - 116 bpm During an interview with RP/FM on 4/17/2025 at 11:58 am, RP stated they were not aware Resident #1 had been refusing to eat or drink since he arrived at the NF. They stated they first they new something was wrong was the morning of 4/11/2025 when a nurse called them to say Resident t#1 was being sent to the ER because he was lethargic and had low vitals. They stated when they got to the ER, Resident #1 told them he had not had anything to eat or drink since he had been admitted on [DATE]. The RP stated if they had known he wasn't eating or drinking they could have gone up to the NF and encourage him to eat, but no one notified them. The RP stated Resident #1 was diagnosed with Kidney Failure and severe dehydration and was very sick and was still in the hospital trying to recover. They stated Resident #1 had been admitted to the NF for rehabilitation and returned to the hospital less than 2 days after he left in worse shape then before. During an interview with CNA-A on 4/17/2025 at 1:52 PM, she stated if a resident refused meals, they were trained to tell the charge nurse. She stated she worked on 4/10/2025 and Resident #1 refused all his meals and hydration except for a small sip of juice. She stated resident was offered 3 meal on 4/10/2025 and refused all of them. She stated she informed the charge nurse and documented in the EMR/POC the resident had consumed 0-25% of his meals. She stated they did not have the ability to choose 0% the only option was a range from 0-25%. During an interview on 4/18/2025 at 9:54 AM, LVN - B stated she completed Resident #1's admission assessment on 4/9/2025 and was the charge nurse for Resident #1 on 4/10/2025. She stated CNA- A informed her Resident #1 had refused meals. She stated CNA-A and her both had tried a couple of times to try and get him to eat and drink and she tried as well, but she refused. She stated she didn't document any of Resident #1's refusals in the EMR because I got busy and didn't get to it. She stated she did not call the RP and notify them of his refusal to eat because I don't know, I guess I thought he was his own RP. She stated at some point during the day, NP D was in the building doing rounds, but she didn't remember if she had told NP D about Resident #1 refusing to eat or drink. She stated a resident who refused to eat or drink could have lower blood pressure, lots of issues with UTIs, dehydration and have to go to the hospital. She noted resident should have been offered at least 4 meals between 4/9/2025 and 4/11/2025 and he was offered dinner on 4/9/25 and 3 meals (breakfast/lunch/dinner) on 4/10/25 and refused all nutrition and hydration expect for a small sip of water in the evening on 4/9/2025. She sated she wasn't sure if Resident #1 had been offered breakfast on 4/11/2025 before the NP-D saw him and ultimately sent him out to the emergency room . During an interview on 4/23/2025 at 12:02 PM, NP-C stated she saw Resident #1 on 4/11/2025 in the morning and he was hard to wake up and wasn't following commands and his heart rate was high, so she gave orders to have him sent to the ER for further care. She stated she reviewed Resident #1's progress notes before going in the building and did not see anything about him refusing meals/hydration. She stated when she arrived at the NF and checked in with Nurse B, Nurse B did not mention anything about Resident #1 missing meals. She stated she would have been concerned if she had known the resident had eaten or drank for 4 meals, and she would have followed up and put interventions in place if she had known which included imagining, labs and perhaps fluid replacement via IV. She stated her concerns for residents refusing that many meals would be dehydration, AMS, and changes in electrolytes. She stated if a resident missed more than 2 meals, her expectation was that staff will reach out to the practitioner so interventions can be started . During an interview on 4/23/2025 at 12:14 PM, NP-D stated she saw Resident #1 in the morning on 4/10/2025 for his initial visit upon admission and noted Resident #1 was Awake, Alert, Calm, Cooperative, Difficulty with speech articulation; PSYCHIATRIC- Oriented times three [indicating resident was alert and oriented to person, place, situation], Clear, Lucid, Normal mood; COGNITIVE- Normal memory. She stated Nurse B did not say anything to her about the resident refusing nutrition or hydration. She stated her concerns for residents who skipped meals was dehydration, possible changes in their vital signs - low blood pressure and increased heart rate, potential changes in cognition. She stated profound dehydration could lead to cardiac disturbances [problems with the heart ]. During an interview on 4/17/2025 at 4:05 PM, the DON stated Resident #1 was seen in person by NP- C and NP-D and reviewed their notes but did not see any notes related to poor intake. She stated her expectation was if a resident missed a couple of meals the staff would notify upper management, the RP and the practitioner. She stated she was not aware the resident had refused to eat or drink and was not aware his RP had not been notified. She stated it was the Nurse B's responsibility to notify the NP and RP of refusal to eat and drink. She stated she was aware his RP was notified when he was sent to theER on [DATE]. She mentioned the NF had NPs in the building 5 days a week and LVN- B should have notified the NPs of Resident's refusal to eat/drink so they could possibly help. During an interview on 4/17/2025 at 4:05 PM, the ADM stated he was unaware Resident #1 had refused meals. He stated his expectation was Staff would notify the DON, RP and practitioner when residents refused meals/hydration. During an interview on 4/23/2025 at 1:55 PM, MDS- E stated she reviewed Resident #1's POC in the EMR and there was not an entry for the evening meal consumption on 4/9/2025 and no entry for breakfast meal consumption on 4/11/2025. She stated three meals were documented for 4/10/2025 showing a 0-25% for each meal that day. She stated there was no way to document 0% of a meal consumed in POC, the nurse would have to put in a progress note in the EMR. She stated she had not seen any progress notes in Resident #1's EMR for 4/10/2025. During an interview on 4/23/2025 at 1:16 PM, the MD stated he was not aware of Resident #1 missing that many meals and he never got any calls about his refusal to eat/drink. He stated even with a couple of days a resident could potentially have kidney issues or dehydration. He stated he reviewed Resident #1 hospital records and noted he had an Acute Kidney Injury, and it took him several days in the hospital to return to his baseline. He stated Resident #1's labs showed he was definitely dehydrated. He stated he would like to know within 2-3 meals if a resident was refusing nutrition/hydration. The MD stated the RP should have been notified if resident was not alert or if the resident was not his own RP. Further, the MD stated, this one didn't go as planned (referring to the notification to the NP's and RP) and the NPs should have been notified of the resident refusing to eat/drink. Record review of the facility's policy, dated/copyright 2025, Resident Rights reflected: Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: a. The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition . Record review of the facility's policy dated/copyright 2024, Notifications of Changes reflected: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. PLAN OF REMOVAL (Immediate Jeopardy) Tag: F580 - The facility failed to notify immediately, the physician and resident representative of a significant change. Facility: Lakeshore Village Nursing and Rehabilitation Date IJ Identified: 5-8-25 Date Plan of Removal Implemented: 5-8-25 Person Responsible for Oversight: Administrator/Designee Immediate Actions Taken to Remove the Immediate Jeopardy 1. Resident #1 (Affected Resident): Upon identification of the issue, Resident #1 no longer resides in the facility. 2. Identification of At-Risk Residents (Facility-Wide Review): DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends on 5-8-25 . This was report pulled from PCC and retained for proof. 6 residents were identified with low or declining intake (<25%) and were immediately evaluated by nursing. NP/MD and RP notifications initiated. Care plans updated accordingly by DON/Designee. No other residents with undetected nutritional significant change. No notifications were required. No other resident with undetected significant change that required notification. 3. System Correction: DON was in-serviced on 5/8/25 by Regional Nursing to notifying MD/NP and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations with return demonstration. DON/ Designee will in-service licensed nursing staff/licensed agency starting 5/8/25 re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations . This will be added to licensed nurses' general orientation for new hires. Mandatory in-services will be completed 5/9/25 with all current and oncoming nursing staff prior to start of shift worked. DON/Designee will complete competency validation conducted for licensed nurses/ licensed agency on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses' general orientation for new hires. Administrator was in-service on department head meal manager schedule and details on 5/8/25 by Texas Area President. Department Heads will be in-serviced by administrator on meal manager requirements. 4. Administrative Oversight/Monitoring: DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily for 30 days and then weekly for 4 weeks ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool. Any issues will be reported to the QAPI Committee meeting monthly. Administrator will lead Ad hoc QAPI to review the deficiency and the process for POR will be completed 5/9/25. 5. Completion Date: 5/9/25 The surveyor monitored the POR on 5/10/2025 as follows: ADM was in serviced by area president on 5/8/2025 on the following: meal managing, reporting meal percentages under 25% to charge nurse, charge nurse reports to NP and RP, and audit completion of residents with poor meal intake. DON was in serviced by regional nurse staff on 5/8/2025 on the following: reporting to physician and families when resident eat less than 25% of meal, meal percentages, accurate reporting of meal percentages, and auditing meal percentages. Interviews with three Nurses, three CNAs and one CMA 5/10/2025 reflected they had been in serviced on letting the charge nurse know when residents consume less than 25% of their meals, and when resident's decline nutrition for two days straight, know percentages and how to validate and document in EMR. The facility completed a complete audit of all resident's meal percentages and identified 6 residents with declining intake and the NP and RPs were notified. AD hoc QAPI was held on 5/9/2025 and the following staff were in attendance: ADM, DON, Regional Nurse, ADONs, Medical Director. The staff reviewed the IJ template for F580 and F692 and reviewed the plan of removal and plan of correction. Record Review revealed the ADM was in serviced on 5//8/2025 on Department head meal manager schedule and details. Record review revealed nursing staff had been in serviced on meal percentages, reporting when residents decline nutrition, and notification of NP/MD and RPs when residents design nutrition for two days. While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not a possible or resident preference indicated otherwise and is offered sufficient fluid intake to maintain proper hydration and health for one of five (Resident #1) residents reviewed for nutrition and hydration. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 refusing meals and hydration from dinner on 4/9/2025 to breakfast on 4/11/2025. Resident was sent to theER on [DATE] with altered mental status resulting in a diagnosis of Acute encephalopathy [altered brain function], Acute renal failure [decreased blood flow to the kidneys] and profound dehydration. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/8/2025 at 12:25 pm; the facility was notified and given an IJ template. While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for immediate harm to their health and safety related to decreased nutritional status, dehydration, UTI's or hospitalization . Findings include: Review of Resident #'s face sheet dated 4/17/2025 reflected a [AGE] year-old male admitted to the NF on 4/9/2025 with diagnoses that included: Cerebral Infarction (stroke - when blood flow to the brain in blocked), Hypertension (high blood pressure), Neoplasm related pain (tumor related pain), Heart Disease, Ataxia (impaired coordination) and Myocardial Infarction (heart attack). Resident #1' s face sheet indicated a FM was his RP and his emergency contact #1. Resident #1's Care Plan dated 4/23/2025 reflected the following problem made on 4/11/2025 after resident was sent to the ER: Potential for alteration in nutrition r/t mechanically altered diet. Resident has been found to pocket food. The following interventions were listed for this problem: document meal intake in the clinical record, notify physician as needed. Review of Resident #1's progress notes dated 4/9/2025 - 4/11/2025 reflected no entries regarding refusal of nutrition or hydration, no entries that practitioners were notified of refusal of nutrition/hydration and no entries that RP was notified of refusal of nutrition/hydration by Resident #1. Review of Resident #1's EMR reflected he had not been in the NF long enough to have a BIMS assessment completed for his cognition. Review of Resident #1's Admission assessment dated [DATE] at 4:12 pm reflected he was drowsy/stuporous but oriented to person, place, time, situation and that his cognition was intact. Review of Resident #1's POC dated 4/23/25 reflected no nutrition/hydration entry for 4/9/2025 or 4/11/2025. There were 3 entries on 4/10/2025 at 8:00 am, 12:00 pm and 5:00 pm in the 0-25% column . Record Review of Resident #1's vital signs revealed he had an admission weight of 134 pounds on 4/9/2025 at 3:35 pm. Vital signs taken between 4/10/2025 and 4/11/2025 revealed resident's oxygen saturation, blood pressure and respirations were within normal limits. Further review of Resident #1's pulse rate revealed pulse rate was elevated and outside of the normal limits (60-100 beats per minute) as follows: 4/10/2025, 10:11 am - 108 bpm (beats per minute) 4/10/2025, 11:57 am - 104 bpm 4/10/2025, 6:19 pm - 105 bpm 4/11/2025, 9:44 am - 116 bpm Record review of Resident #1's ER hospital records, dated 4/18/2025, reflected he arrived at theER on [DATE] at 11:33 AM and upon arrival Patient hypoxic [absence of enough oxygen in the tissue to sustain bodily functions] and hypotensive [blood pressure below normal limits] enroute with BP 75/45, placed on 2L NC . presenting with c/o generalized weakness and AMS. Resident #1 was diagnosed with Acute encephalopathy [altered brain function], Acute renal failure [decreased blood flow to the kidneys] and profound dehydration which required him to be admitted for further treatment. The records indicated Resident #1 was still hospitalized as of 4/18/2025. During an interview with RP/FM on 4/17/2025 at 11:58 AM, the RP stated they were not aware Resident #1 had been refusing to eat or drink since he arrived at the NF. They stated they first knew something was wrong was the morning of 4/11/2025 when a nurse called them to say Resident t#1 was being sent to the ER because he was lethargic and had low vitals. They stated when they got to the ER, Resident #1 told them he had not had anything to eat or drink since he had been admitted on [DATE]. RP stated if they had known he wasn't eating or drinking they could have gone up to the NF and encourage him to eat, but no one notified them . During an interview with CNA A on 4/17/2025 at 1:52 pm she stated if a resident refuses meals, they are trained to tell the charge nurse. She stated she worked on 4/10/2025 and Resident #1 refused all his meals and hydration except for a small sip of juice. She stated she informed the charge nurse and documented in the EMR/POC that resident had consumed 0-25% of his meals. She stated they do not have the ability to choose 0% the only option is a range from 0-25%. During an interview with Nurse B on 4/18/2025 at 9:54 am she stated she was the charge nurse for Resident #1 on 4/10/2025. She stated the CNA A informed her that Resident #1 had refused meals. She stated CNA A tried a couple of times to try and get him to eat and she tried as well, but her refused. She stated she didn't document any of Resident #1's refusals in the EMR because I got busy and didn't get to it She stated she did not call RP and notify them of his refusal to eat because I don't know, I guess I thought he was his own RP. She stated at some point during the day, NP D was in the building doing rounds, but she didn't remember if she had told NP D about Resident #1 refusing to eat or drink. She stated a resident that refuses to eat or drink could have lower blood pressure, lots of issues with UTIs, dehydration and have to go to the hospital. During an interview on 4/23/2025 at 12:02 pm, NP C stated she saw Resident #1 on 4/11/2025 in the morning and he was hard to wake up and wasn't following commands and his heart rate was high, so she gave orders to have him sent to the ER for further care. She stated she reviewed Resident #1's progress notes before going in the building and did not see anything about him refusing meals/hydration. She stated when she arrived at the NF and checked in with Nurse B, Nurse B did not mention anything about Resident #1 missing meals. She stated she would have been concerned if she had known that resident had eaten or drank for 4 meals, and she would have followed up and put interventions in place if she had known including imagining, labs and perhaps fluid replacement via IV. She stated her concerns for residents refusing that m any meals would be dehydration, AMS, and changes in electrolytes. She stated if a resident misses more than 2 meals, her expectation is that staff will reach out to the practitioner so interventions can be started. During an interview on 4/23/2025 at 12:14 pm, NP D stated she had seen Resident #1 in the morning on 4/10/2025 for his initial visit upon admission and noted Resident #1 was Awake, Alert, Calm, Cooperative, Difficulty with speech articulation; PSYCHIATRIC- Oriented times three [indicating resident was alert and oriented to person, place, situation], Clear, Lucid, Normal mood; COGNITIVE- Normal memory. She stated Nurse B did not say anything to her about resident refusing nutrition or hydration. She stated her concerns for residents that skip meals is dehydration, possible changes in their vital signs - low blood pressure and increased heart rate, potential changes in cognition. She stated profound dehydration could lead to cardiac disturbances [problems with the heart]. During an interview on 4/17/2025 at 4:05 PM, the DON stated Resident #1 was seen in person by NP- C and NP-D and reviewed their notes but did not see any notes related to poor intake. She stated her expectation is was that if a resident misses missed a couple of meals that the staff will would notify upper management, the RP and the practitioner. She stated she was not aware the resident had been refusing to eat or drink and was not aware his RP had not been notified. She stated it was the Nurse B's responsibility to notify the NP and RP of refusal to eat and drink. She stated she was aware his RP had been notified when he was sent to theER on [DATE]. She mentioned that the NF has had NPs in the building 5 days a week and that LVN- B should have notified the NPs of Resident's refusal to eat/drink so they could possibly help. During an interview on 4/17/2025 at 4:05 pm, ADM stated he was unaware that Resident #1 had been refusing meals. He stated his expectation is that Staff will notify DON, RP and practitioner when residents refuse meals/hydration. During an interview on 4/23/2025 at 1:16 pm, MD stated he was not aware of Resident #1 missing that many meals and that he never got any calls about his refusal to eat/drink. He stated even with a couple of days a resident could potentially have kidney issues or dehydration. He stated he reviewed Resident #1 hospital records and noted he had an Acute Kidney Injury, and it took him several days in the hospital to return to his baseline. He stated Resident #1's labs showed he was definitely dehydrated. He stated he would like to know within 2-3 meals if a resident is refusing nutrition/hydration. MD stated the RP should have been notified if resident was not alert or if resident was not his own RP. Further, the MD stated, this one didn't go as planned (referring to the notification to the NP's and RP) and the NPs should have been notified of the resident refusing to eat/drink. Record review of the facility's policy Nutritional Management, copyright 2025, reflected: Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Definitions: Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. Nutritional Status includes both nutrition and hydration status. 5. d. The physician will be notified of: i. Significant changes in weight, intake, or nutritional status ii. Lack of improvement toward goals iii. Any complications associated with interventions. 6. Informed consent: a. The resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status. b. The facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives, as appropriate. PLAN OF REMOVAL (Immediate Threat) Tag: F692 - Failure to Maintain Acceptable Parameters of Nutritional Status Facility Date IJ Identified: 5-8-25 Date Plan of Removal Implemented: 5-8-25 Person Responsible for Oversight: Administrator/Designee Immediate Actions Taken to Remove the Immediate Threat 1. Resident #1 (Affected Resident): Upon identification of the issue, Resident #1 no longer resides in the facility. 2. Identification of At-Risk Residents (Facility-Wide Review): DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends on 5-8-25. 6 residents were identified with low or declining intake (25% or less) and were immediately evaluated by nursing. NP/MD and RP notifications initiated. Care plans updated accordingly by DON/Designee. No other residents with undetected weight loss No other resident with undetected significant change that required notification. 3. System Correction: DON/ Designee will in-service Licensed nursing/ licensed agency staff immediately re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations . This will be added to licensed nurses' general orientation for new hires. DON/ Designee will in-service CNAs/Agency CNA immediately re-educated and directed to notify charge nurse of missed meals or poor intake (<25%), accurate documentation and communication expectations . This will be added to CNAs general orientation for new hires. Mandatory in-services will be completed 5/9/25 with all current and oncoming nursing staff prior to start of shift worked. Competency for License staff and CNAs/Agency CNAs validation conducted on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses/CNAs general orientation for new hires. Administrator was in-serviced on department head meal manager schedule and details on 5/8/25 by Texas Area President. Department Heads will be in-serviced by administrator on meal manager requirements . 4. Administrative Oversight/Monitoring: DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily for 30 days and then weekly for 4 weeks to ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool. Any issues will be reported to the QAPI Committee meeting monthly. Ad hoc QAPI to review the deficiency and the process for POR will be completed 5/9/25. 5. Completion Date: 5/9/25 POR monitoring as above in F580 While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

50176 Based on observation, interview, and record review, the facility failed to ensure that the menus met the nutritional needs of residents in accordance with established national guideline, were prepared in advance, were followed or appropriate substitutions were made, and reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy for 1 of 1 kitchen reviewed for menu accuracy. 1) The facility failed to ensure the DM created a menu in advance and the menu had reviewed and approved by the regional dietitian for the special incentive lunch meal served in the dining room. 2) The facility failed to ensure [NAME] H served adequate portion sizes for residents during the lunch meal on [DATE] when he did not use the correct scoop size and served food portions with his hands. 3) The facility failed to make sure that its menus were followed and documented any substitutions made to the menus for soft mechanical and puree diets for 10 residents on [DATE]. These failures placed residents at risk of poor intake, possible weight loss, and diminished quality of life. Findings included: Observation and interview in the kitchen on [DATE] at 08:56 AM revealed [NAME] H pulled meatballs out of the oven and put them in the grinder. He stated those were for the soft mechanical and puree diets. At 9:04 AM, [NAME] H was observed placing the ground beef meatballs on the steam table. Observation of the main dining on [DATE] at 12:05 PM revealed no menu was posted on the bulletin board labeled Today's menu. The wall next to the kitchen revealed a posted menu for the week, in very small print, which was not easily viewed by residents. Residents in the dining room were served chili hot dogs, potato chips, and baked potatoes. No meal tickets were observed for the hot dogs with chili, baked potatoes, or potatoes chips that were observed (not on menu). Staff were observed to yell out the resident's order. Review of meal tickets on meal carts being served to residents eating in their rooms reflected, [NAME] sugar glaze ham, candied sweet potatoes, fried okra, [NAME], cornbread, fresh orange slices and other condiments. Observation in the kitchen on [DATE] at 12:40 M revealed [NAME] H used his gloved hands to portion out pieces of ham and fried okra on residents' trays. He did not use the correct utensils or spoon. Also observed a container of macaroni and cheese. Observation and interview on [DATE] at 12:50 PM, revealed the kitchen had run out of glazed ham and ten residents' plates were left to be served on the 200 hall. The DM stated that they would serve hamburger patties as an alternative because they ran out of glazed ham. Observed planned menu for lunch: brown sugar glazed ham, candied sweet potatoes, fried okra, margarine, cornbread, sugar, salt, pepper, non-diary creamer, fresh orange slices, coffee or tea, and milk. In an interview on [DATE] at 09:19 AM the DM stated the thawed beef patties would be served at lunch. In an interview on [DATE] at 11:51 AM the DM stated using hands to serve food was not acceptable. Staff needed to use utensils for portion control and to avoid cross contamination. Everything was measured out according to the diet type and recipe and some residents could only have a few ounces of food and others needed double portions. That would not meet her expectations because staff could not measure portion sizes with their hands. These behaviors were not good, and it did not meet her expectations. The DM stated the meal served in the dining room was not listed on the menu. She came up with the idea and had been doing it for about two months. She gave examples of what had been served: Chili dogs, brisket, salad, baked potatoes, fajitas, taco soup, etc. and those were not listed on the menu. It was like a side dish and stated those didn't need a menu or recipe. She was not aware of any policy or procedure and there was no process. She stated she knew all the residents' meal types and knew which residents could have which kinds of meal textures. The different food served in the dining room was an incentive to bring residents out of their rooms to get different food. Residents that ate in their rooms could not get this special meal. Observation on [DATE] at 01:22 PM of the lunch test tray revealed a beef hamburger patty with brown gravy, baked potato, cooked zucchini, apple slices, roll, and sour cream. Review of the menu and a meal ticket reflected rosemary sage beef, baked potato, seasoned zucchini, margarine, wheat roll, sugar, salt, pepper, non-dairy creamer, fresh apples slices, coffee or tea, and milk. In an interview on [DATE] at 09:20 AM, the DA stated that she received training on using the correct scoop, per the recipe, when serving out residents' food trays. She stated that she would never use her hand to serve food due to the risk of cross contamination. She said the side bar was created by someone, but there were no menus, and she didn't know if there was a policy. The staff would tell residents what was being served after they arrived in the dining room. There were no meal tickets for the side bar but the DM or the therapist were in the dining room and knew which residents could have certain meal types. In an interview on [DATE] at 09:33 AM, [NAME] I stated she received orientation training on different types of meal, how to serve plates, menu, reading the meal ticket, hair nets, glove use, hand hygiene, using scoops for serving food, and many other topics. [NAME] I stated she would never use her hands to portion food for residents' plates, even if she was wearing gloves because it was not sanitary and could make the residents sick. [NAME] I stated that if the kitchen ran out of the main protein/entree or any other item listed on the menu, she would use an alternative that was listed on the menu for that day/that meal. That information would be documented on a substitution form kept in the kitchen and stated she had to list the date, item on menu that was substituted, what was the substitution and why it was substituted so it could be approved. If they ran out of glazed ham and had to serve hamburger patties instead, that information would be listed on the menu substitution approval form kept in the kitchen. There was no menu for the items served on the salad/side bar in the main dining room. She stated residents have meal tickets printed in the kitchen and the kitchen staff knew which residents have different meal types and that was how they controlled ensuring the correct meal type was given to the resident. In an interview on [DATE] at 09:58 AM, the DM again stated that she created the special dining room meal and there were no menus. She stated that the nurses and therapy staff were in the dining room with the residents to ensure they were getting the correct meal. In an interview on [DATE] at 10:04 AM, the ST stated she was not aware who had come up with the idea of the special meal served in the dining room and was not sure if they had a process, policy, or procedure about it. There were no menus about the food. She was not aware of any residents being served the wrong texture diet. In an interview on [DATE] at 10:13 AM, the DON stated the kitchen staff should be using measured spoons for the correct portion size and not serve food with their hands due to infection control concerns. Also, the residents must get a certain number of calories and the amount that was ordered and there was no way to accurately measure portions with your hands. This would not meet her expectations. The DON stated that the DM came up with the idea of the special incentive meals served in the dining room, also known as the salad bar only after the ADM suggested the residents needed more food options. It had been going on for about 3 to 6 months. She stated there was no way to monitor how much nutritional value from the salad bar so the residents were offered the regular meal as well and they could accept or decline it. There were no menus for the food items being served and therefore, no meal tickets. The DON stated it is the nurse's responsibility to monitor and review the meal tickets to ensure the residents were getting the appropriate meals (low sodium, low carbohydrate, mechanical soft, puree, etc.) and it started in the kitchen with kitchen staff reviewing those meal tickets. In a telephone interview on [DATE] at 11:10 AM, the dietitian stated that she visited the kitchen once a month and completed a walk-through checking for, among other things, tray line for portion sizes, scoop sizes, tray accuracy, and monitoring temperatures, which have all been ongoing issues. She stated she was aware of the special meal service for the dining room residents. She was not involved in the process, and she did not believe there was any formal process or procedure. There were no menus. She had not approved a menu, but when she had looked at what was being served sometimes, she thought it appeared balanced and never commented on it. She stated it was the resident's rights to request the special dining food, even if it was not aligned with the resident's dietary orders. When asked if she thought chili hot dogs were considered an appropriately meal for a resident with low sodium or low carbohydrate, the dietitian did not answer and stated it was the resident's right to request this special food. When asked if she thought chili hot dogs were considered an appropriately for a resident with a mechanical soft diet and she stated only if they got the speech therapist involved and the speech therapist approved it. Observation of the main dining on [DATE] at 12:10 PM revealed no menus were posted. The staff did not know what was being served on the special incentive meal and were overhead asking kitchen staff what was being served. Lunch in the dining room was potato clam soup, salad with tomatoes and cucumbers, and fresh fruit (whole red and green grapes, cut strawberries, blueberries, and blackberries). Review of the menu for [DATE] reflected lunch was chicken parmesan or glazed meatloaf, buttered spaghetti or garlic mashed potatoes, buttered beets, tossed salad, wheat bread with margarine, chilled pears, and other condiments and drinks. In an interview on [DATE] at 01:14 PM, the ADM stated the special meal in the dining room was set up to encourage residents to come to the dining room for service. The DM came up with the idea. The ADM stated the speech therapist and multiple nurses were in the dining room to ensure residents were getting the correct meal type/diet order. There were no menus, because it was not considered a meal, but rather an appetizer. It varied and was different daily. The residents were still being offered their regular meal trays. He was not aware of any policy or procedure for this. Observation on [DATE] at 01:32 PM of the lunch test tray revealed chicken parmesan, buttered spaghetti, tossed salad, wheat bread, chilled pears, and a drink. Review of the kitchen in-service training dated [DATE] reflected kitchen staff had been trained on the topic of tray line and checklists for menu compliance. Review of the kitchen in-service training dated [DATE] reflected kitchen staff had been trained on following recipes, using scoop and ladle sizes, and the conversion table. Review of the facility's Menu Substitution Approval Form dated February 2025 reflected no entries for [DATE]. On [DATE], the only substitution listed was for coffee cake at breakfast. Substitutions made on [DATE] and [DATE] did not list the meal or reason for the substitution. Review of the facility's undated Menu Substitution Guide reflected, Choose any food within the same list as a substitute for the unavailable food. Substitute only within each group. Record the substitution on the menu and have the dietitian initial the change . Review of the facility policy titled Tray Line Service approved [DATE] reflected: Policy: The consultant dietitian will monitor the tray line to ensure that diets are served accurately and in the correct portions and that patient/resident preferences are met . The following guidelines should be followed. Guidelines: 1. A dated copy of the daily menu extensions with any changes is posted in the kitchen near the tray line so that the servers can use the extensions to correctly serve the diets. 2. The trays are prepared by the server using the diet extensions and the portion sizes listed on the extensions. 4. Each tray is checked by the tray line personnel to ensure that the diet is served as ordered, the portion size of each item is correct, and preferences are met. The Dietary Manager conducts a tray line audit once each week for each meal to ensure that diets are served correctly and to identify any training needs. Review of the facility policy titled Holiday and Special Meals Policy approved [DATE], reflected: Policy: The facility believes that the quality of life for its residents should be maximized whenever possible. On holidays or special occasions, all residents will be served the same menu provided the physician has approved diet liberalization on such occasions. Procedure: 2. The menu for the holiday or special occasion will be planned during the resident council meeting or other meeting where resident input can be obtained. 3. The consultant NDTR or RDN will review and approve the holiday or special occasion menu for adequacy and appropriateness for the resident population. The menu will be extended by the dietitian/NDTR for all diets offered at the facility. 5. Texture modifications, such as ground meats or pureed, will be prepared for residents requiring texture modification. Thickened liquids will be provided as ordered by the physician. Review of the facility policy titled Menu Planning approved [DATE] and revised [DATE], reflected: Policy: The facility believes that nutrition is an important part of maintaining the wellbeing and health of its residents and is committed to providing a menu that is well balanced, nutritious and meets the preferences of the resident population. A standardized menu which meets the nutritional recommendations of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences will be used. Modifications for resident population and preferences may be made as appropriate. Procedure: 3. The menus are reviewed and approved by the Consultant Dietitian. Intermittent changes must also be reviewed and approved by the Consultant Dietitian. 4. The menu will be signed and dated by the Consultant Dietitian. An approved, signed copy of the menus will be kept on file in the Nutrition & Foodservice Manager's office. 5. Dated current menus will be posted in all dining areas. Review of the facility policy titled Menu Substitutions approved [DATE] and revised [DATE], reflected: Policy: The facility believes that a well-balanced menu, planned in advanced and served as posted, is important to the well-being of its residents. The menus will be served as planned except for emergency situations when a food item is unavailable. Procedure: 1. The menu will be served as written unless an emergency situation arises. 2. If a specific item is not available, the cook will consult with the Nutrition & Foodservice Manager or consultant RDN/NDTR regarding an appropriate substitution. If the Nutrition & Foodservice Manager or dietitian is not available, the cook will refer to the Menu Substitution Guide included in this section and their approved diet manual. 3. All substitutions will be made in accordance with the Menu Substitution Guide to ensure that the meal is well-balanced and adequate. 4. All changes to the menu will be recorded on the Menu Substitution Approval Form. 5. The consultant RDN/NDTR will review the Menu Substitution Approval Form with the dietitian on each visit to determine trends in substitutions and accuracy of substitutions so that appropriate training can be provided if needed. 6. The dietitian will initial off the Menu Substitution Form after review. 7. The Menu Substitution Form will be retained with the dated menus for a 12- month period. 8. Liberalized meals, theme and holiday meals, buffets and other altered mealtime experiences are encouraged. However, such alterations must have extensions and be approved by the consultant RDN/NDTR to ensure adequacy and safety for those residents on mechanically altered diets . Review of the facility policy titled Alternative Food Choices and Substitutions and Honoring Preferences approved [DATE], reflected: The facility believes that adequate nutrition is essential to each resident's wellbeing and good health. An alternate entree and vegetable will be offered at each meal. The facility also supports resident choice and allowing residents to choose food by honoring their food preferences. Other substitutions will also be available in the event a resident does not choose the main meal or the alternate. Procedure: 1. Residents will be informed on admission that there is an alternate for each meal and will also be informed of substitutions which are available on a daily basis. 2. Residents will be served the main menu at each meal unless they request the alternative. 5. Nursing staff will observe the residents at mealtime. Any resident not eating will be offered the alternate meal or a substitute from the items available in the kitchen. The items offered must be compatible with any dietary restrictions or texture modifications. Review of the facility's policy titled Portion Control dated [DATE] reflected: Policy: The facility will use standard portion control procedures and utensils to ensure that adequate portions are served to residents. Procedure: 1. Standardized recipes should be used to prevent over-production. Recipes should be adjusted as needed to provide the amount of servings required. Amounts may vary when various serving methods and menus are utilized. 2. A dated copy of the daily menu extensions with portion sizes should be posted in the kitchen near the preparation and serving areas. 3. Portions for each food item should follow the specific portion sizes listed on the menus. 4. Food items should be served using standard size ladles, scoops, spoodles and spoons. Standard scoop and ladle sizes are listed . Note: Weights vary greatly with different foods, depending on how compact they are. The best practice is to weigh an item before proceeding with portioning. Dipper numbers are usually portions per quart.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen and two of two nourishment rooms reviewed for food and nutrition services. 1) The facility failed to close food product bags in the three-door freezer to prevent exposure to air. 2) The facility failed to label and date food items in the side-by-side refrigerator, freezer, and the two nourishment refrigerators. 3) The facility failed to ensure that one of their three-door freezers was maintained at acceptable temperatures which resulted in frozen foods thawing out and then re-freezing without being discarded. 4) The facility failed to maintain a sanitary environment for food preparation when [NAME] H was observed opening a package of food with his mouth, eating a bowl of cereal while cooking, and using his gloved hand to portion food for resident trays after touching multiple surfaces in the kitchen. 5) The facility failed to ensure proper hair restraints were worn in the kitchen. 6) The facility failed to reheat and hold food at the proper temperature when they reheated cold chili on the steam table and served it from a crockpot. 7) The facility failed to maintain the proper temperature of the refrigerator in nourishment room A. 8) The facility failed to maintain a sanitary open front refrigerator/freezer in the nourishment room A. 9) These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness. Findings included: Observation of the kitchen on [DATE] at 08:46 AM of the facility's three door side by side freezer revealed two open bags of frozen beef patties that were not properly sealed, were exposed to air, not dated, and one bag had significant freezer burn and ice. Also inside the freezer was an open bag of unidentified frozen patties that were not properly sealed, were exposed to air, not dated nor labeled, a closed bag of unidentified frozen food dated [DATE], and open box of frozen boneless, skinless chicken breast with rib meat with the bag inside opened and exposed to air and not dated. Observation on [DATE] at 08:53 AM of the kitchen side by side refrigerator revealed an open cardboard box dated [DATE] containing two plastic bags of thawed chicken legs and other chicken pieces. Both bags had been previously opened and were closed and neither bag was dated. There was also one large unopened tube of thawed ground beef that was not dated. Observation on [DATE] at 08:56 AM revealed [NAME] H wore a beard guard around his chin/beard, but not his full mustache. The beard guard was pulled down to expose his mustache. Observation on [DATE] at 09:02 AM revealed a cold container of chili dated ,d+[DATE] on a cart in the kitchen. At 09:10 AM it was moved to the kitchen counter and the state surveyor felt the outside of the foil container, which was cold to the touch. Then observed the DM put in in the steam table. Observation on [DATE] at 09:07 AM revealed the DW wore a beard guard around his chin/beard, but not his full mustache. The beard guard was pulled down to expose his mouth and mustache. Observation on [DATE] at 09:08 AM revealed [NAME] H used his teeth to open a plastic bag of brown gravy mix and then poured the mix into a pot on the stove and made gravy. While cooking, at 09:13 AM, [NAME] H ate two bowls of cereal as he stood at the food prepping table next to the cornbread he had just taken out of the oven, and while he walked around the kitchen. Observation on [DATE] at 12:04 PM in the main dining room revealed a table set up on the side with three uncovered crockpots: One contained chili, one had hotdogs, and the other was full of foil wrapped baked potatoes. The crockpot containing the chili was plugged in and the green power light was flashing, but it was not set to low, high, or warm. The crockpot containing the hot dogs had a missing knob. There was not a knob to indicate if it was off, low, high, or the warm setting. The residents in the dining room were being served chili hot dogs. Observation and interview on [DATE] at 12:21 PM revealed the DM unplugged two crockpots. The DM stated that they took temperatures on the steam table before moving the food to the crockpots and then kept the crock pots on low. The DM stated that one crockpot knob had broken off when it was on low and that was how she knew what temperature setting it was on. The DM stated they took temperature readings during serving. The survey team did not observe this. The DM checked the temperature of the hot dogs, by laying the thermometer in the liquid that read 140 degrees, not the hot dog. When the state surveyor asked the DM to re-measure, the DM picked up the thermometer and stuck it in the hot dogs and said, see, it's 140 degrees. The DM stated that food on the steam table needed to be held at 140 degrees Fahrenheit or higher. At 12:25 PM, the DM measured the temperature of the chili at 110 degrees Fahrenheit. The DW stated that the chili had lost heat due to sitting unplugged on the table and stated that the temperature should be at least 140 degrees Fahrenheit to avoid making residents sick due to food borne illnesses. The DM stated it was not her expectation that the crockpots be covered because it was a salad bar and salad bars are open and not covered. Observation on [DATE] at 12:39 PM of the kitchen side by side refrigerator revealed an unlabeled open bag of what appeared to be bacon bits dated [DATE] that was not properly sealed and had no use by date. The thawed chicken pieces and ground beef were still there undated. Observation on [DATE] at 12:40 PM revealed [NAME] H wore a beard guard around his chin that exposed his mustache. [NAME] H used his gloved hands to portion food for resident trays on the tray line. Without changing gloves, [NAME] H picked up pieces of ham and fried okra and put them on residents' plates, touched other clean plates, the food tray and cover, the meal cart, and the steam table surface. At 12:47 PM [NAME] H used the same gloved hand to pick up a large pan and handle frozen meat patties. Observation in the kitchen on [DATE] at 07:35 AM revealed [NAME] H wore a beard guard around his chin, but not covering his mustache. At 7:40 AM the side-by-side refrigerator was observed with one unlabeled sandwich in plastic baggy, a foil covered container containing lettuce/salad that was not labeled nor dated, a large tube of thawed ground beef not dated (the same tube seen as on [DATE]), and one opened tube of thawed ground beef that was not properly sealed, exposed to air, and not dated. The same box of chicken pieces dated [DATE] was there with the same thawed chicken pieces. Observation on [DATE] at 07:44 AM revealed that the facility's second three door freezer's exterior thermometer displayed 41.3 degrees Fahrenheit. The freezer had a temperature log on the middle door which indicated the last recorded AM temperature of 41 on [DATE] and the last PM temperature of -1.2 degrees on [DATE]. Observation revealed the last of the three doors were open because a box on the top shelf stuck out and prevented the door from closing all the way. Observation of interior contents of the freezer revealed several boxes of sealed seafood items, a bag of fish sticks, several bags of beef patties, unlabeled and undated bag of frozen food, and large brisket/roast meats. The beef patties and fish sticks were not frozen and easily broken or crumbled when the state surveyor touched them. The unlabeled bag of food had condensation inside the plastic bag and the contents were soft to the touch. All the food items that were not boxed, that the state surveyor could see, were not frozen, except for the very large brisket/roast meats. Observation and interview on [DATE] at 09:19 AM revealed that the facility's second three door freezer's exterior thermometer displayed 26.3 . The DM stated she was not aware of the freezer temperature until she observed the state surveyor looking at the freezer earlier that morning. The DM stated that when the freezer temperature was noticed, a corrective action should have been done, including checking for the source of the problem, and reporting it to her. The DM stated the thawed beef patties would be served at lunch. She did not do anything with the fish sticks nor other items in the freezer and stated the freezer temperature had returned to normal, so no action was needed. In the same interview, the DM stated it was the facility's policy to have an open date when food was opened to ensure it was used timely. When asked about the frozen beef patties with no open date and freezer burn, the DM threw them in the trash and stated that staff had probably left them too long on the counter and they thawed and then refroze. The DM stated it was important to throw out the meat because they had reached unsafe temperatures, thawed out and it would reduce the quality of taste. The DM stated there was a poster on the wall that listed how long meat could stay in the refrigerator before it was used. Regarding the open box of thawed chicken pieces in the refrigerator, the DM stated that chicken should have been labeled and dated and put in the refrigerator or cooked the same day. It was already thawed and there was no way for her to know how long it had been in the refrigerator since it was not dated. This did not meet her expectations. The DM took the box of chicken and placed it outside to throw away. Regarding the tube of thawed ground beef, the DM stated that she thought it was thawed on Sunday, [DATE], and left it in the fridge. She stated it was it was the kitchen staff's responsibility to label and date food items taken out to thaw. The DM stated that she walked through the kitchen twice a week to audit the refrigerator and would discard food with no date. If it had no date, she had no way of knowing how old the food was and if used, could make residents sick. She had not noticed the food that was not properly labeled and dated, and this did not meet her expectations. In an interview on [DATE] at 09:41 AM and 10:26 AM, [NAME] H stated he checked the temperature on the freezer around 6:30 AM and it was 41 . He logged it on the temperature log. [NAME] H stated he did not notice the freezer door was open until he saw the state surveyor looking at the freezer. He did not take any action and did not notify anyone. He could not say what he should have done. He stated that he continued cooking breakfast. He did not know how long the temperature had been out of range and stated he did not know how to answer the question about if the temperature out of range concerned him. [NAME] H stated it was important for frozen foods to stay frozen because otherwise the food would thaw and go bad. Expired food or food not kept at the appropriate temperatures could make residents sick. Cook H stated he had received training in hand and kitchen hygiene, hair nets and beard guards, and other kitchen trainings. He stated he should wear a hair net and beard guard anytime he was in the kitchen due to the risk of hair getting in food, which could cause cross contamination. He stated he trimmed his mustache yesterday because it was long. When asked if he should wear his beard guard over his mustache he answered yes. [NAME] H stated that he regularly opened bags of food with his fingers or teeth because he did not have time to grab a pair of scissors. [NAME] H stated that it was not sanitary to use his teeth to open a food bag because his germs could get in the food, and it would not be sanitary. [NAME] H stated that meat was thawed and then cooked. He could not say how long thawed meat should be in the fridge before it was used. He did not know how long the thawed chicken or ground beef had been in the refrigerator and he could not say what the process was for labeling and dating. Observation and interview on [DATE] at 09:59 AM, revealed the DW wore a beard guard around his beard, but not his mustache. The DW hand carried clean dishes and plate covers from the dishwasher area into the food prep area. The DW stated before starting work, he received training on hairnets, beard guards, and hand sanitation. The DW stated he knew to wear a hairnet anytime he handled food and always a beard guard when he was in the kitchen. The DW stated the beard guard should cover all his hair on his face and he acknowledged it did not cover his mustache. The DW then pulled the beard guard over his mouth and covered his mustache. The DW stated it was important to cover all his hair to avoid hair getting on plates or in the food, which would not be sanitary and could make residents sick. Observation on [DATE] at 11:37 AM, revealed the DW stood in the dishwasher area and wore a beard guard around his beard, but not his mustache. In an interview on [DATE] at 11:51 AM the DM stated using hands to serve food was not acceptable. Staff needed to use utensils for portion control and to avoid cross contamination. The DM stated all male kitchen staff should wear beard guards that cover all facial hair and not doing so could cause cross contamination and make residents sick if hair got in the food. The DM stated that using teeth to open food containers was inappropriate. She stated that if a staff could not open the container with their hands, then they should use the kitchen scissors to avoid the risk of cross contamination. The DM stated that the kitchen staff had training on these topics and know what to do and what not to do in the kitchen. Staff should not be eating in the kitchen prep areas. These behaviors were not good, and it did not meet her expectations. In an interview on [DATE] at 09:20 AM, the DA stated that she received training on proper hair restraints, hand hygiene, and using the correct scoop, per the recipe, when serving out residents' food trays. She stated that she would never use her hand to serve food due to the risk of cross contamination. The DA stated that all food should have three dates on them. Food was to be labeled with the date received, date it was opened, and expiration date/used by. She did not know how long food could stay in the refrigerator but thought it was ,d+[DATE] days. She did not do anything with thawed food and did not know the process. She received training not to eat in the kitchen due to the risk of cross contamination. She did not check the temperatures on refrigerators or freezers and stated that was the cooks or DM's responsibility. In an interview on [DATE] at 09:33 AM, [NAME] I stated she received orientation training on different types of meals. How to serve plates, menu, reading the meal ticket, hair nets, glove use, hand hygiene, using scoops for serving food, and many other topics. [NAME] I stated she would never use her hands to portion food for residents' plates, even if she was wearing gloves because it was not sanitary and could make the residents sick. She stated you could not eat in the kitchen food preparation area due to the risk of cross contamination and it would not be sanitary. [NAME] I stated they have a break room staff could use. [NAME] I stated she would use scissors to open food containers and would never use her mouth to open food containers or bags due to germs and cross contamination. [NAME] I stated she thawed meat in cold running water. At night, staff might take out frozen food and put in refrigerator to thaw and it needed to have a date on it. The food must be labeled with three dates: the date received, the date opened, and date to use by. [NAME] I stated she didn't know how long thawed meat could stay in the refrigerator because she always used it the same or next day. She was able to find a piece of paper in the kitchen that showed the length of time food could remain in fridge before being used or discarded. Without a date, she wouldn't know when it had been placed in the refrigerator and would discard the food to ensure it was safe for residents and not make them sick. In an interview on [DATE] at 10:13 AM, the DON stated the kitchen staff should be using measured spoons for the correct portion size and not serve food with their hands due to infection control concerns. The DON stated kitchen staff should not use their mouths to open food containers because mouths were dirty, and it was an infection control concern. The DON stated she didn't know what the policy was about eating in the food preparation area but would not do it due to cross contamination and that would not be sanitary. All kitchen staff must wear proper hair nets and beard restraints when in the kitchen to avoid cross contamination and not doing so would not meet her expectations. In a telephone interview on [DATE] at 11:10 AM the dietitian stated that she visited the kitchen once a month and completed a walk-through checking for sanitary conditions. She also checked the tray line for portion sizes, scoop sizes, tray accuracy, and monitoring temperatures, which have all been ongoing issues. The dietitian stated that once frozen food had thawed, it must be cooked the same day or throw it away. It should not be re-frozen as food had reached an unsafe temperature where bacteria could grow making the food hazardous to eat. She stated she provided training to kitchen staff regarding proper hair restraints, beard guards, hand sanitization, and not eating near the food preparation area. She stated that kitchen staff could use their clean gloved hands to serve food if it had not touched any other surface and they would need to change gloves after each task. Serving food after touching the counter, meal tray, plate, and other food items would not be sanitary and would not meet her expectations. In an interview on [DATE] at 01:14 PM, the ADM stated his expectation was for staff to wear proper hair nets and beard guards while in the kitchen, not to eat in the kitchen, and not use their teeth or mouth to open food containers because that was gross and was not sanitary conditions. The ADM was unaware of the freezer temperature conditions and could not say what to do. The ADM stated he would consult with the DM, dietitian, and review policy. Observation and interview on [DATE] at 03:11 PM of nourishment room A revealed a sign on the refrigerator door listed, Label and date all residents food or it will be thrown away and to fill out temperature logs. The temperature log on [DATE] at 0200 (02:00 AM) showed 40 degrees. In the refrigerator, there were three plastic bags with food inside with a date on the outside of the bag but was not labeled with a resident's name. A bag of fast food was not labeled nor dated and contained a sandwich. The fridge door shelf and inside bottom shelf was dirty with red and brown stains. Observation of the inside thermometer revealed 44 degrees Fahrenheit. The freezer shelf was dirty with brown residue stains. Three frozen food items in freezer were not labeled with resident's names nor dated. The DON stated residents do not have access to the nutrition rooms, only the nursing staff, and food should be labeled with residents' names to keep track of whose food it was. Observation and interview on [DATE] at 03:18 PM of nourishment room B revealed a sign on the refrigerator door, Please do not place anything in fridge without date, resident's name, and date open on milk, etc. There was a tray of snack food containing, among other items, three half sandwiches that were not labeled nor dated. An unidentified nurse staff came in and stated those were three chicken salad sandwiches. She had just put that food tray in and was about to label and date it but had to go get a pen. The DON stated nursing staff should be cleaning weekly. There was no cleaning log. The DON was not aware of any policy regarding food brought in by residents or family members, but stated the process was to label each food item with the resident's name and date. Fresh food, like the fast-food sandwich observed, would be discarded within 24 hours if not eaten. Review of the kitchen in-service training dated [DATE] and [DATE] (no year listed) reflected kitchen staff had been trained on staff hygiene, including hair nets and beard guards. Training reflected All Food Handlers Are Required to wear effective hair restraints that cover all exposed body hair. o Include Caps, hats. nets, scarves, bear restraints, and other reasonable hair containment forms. Hair Nets/Beard Guards serve two purposes: o Keep hair from contacting exposed food, clean and sanitized equipment, utensils and linens, or unwrapped single-service articles. o Keep worker's hands out of their hair. Review of Hair restraints summary dated [DATE] was signed by [NAME] H on [DATE]. Review of the kitchen's in-service training undated titled Monthly Review reflected: Make sure all items have 3 label dates. Examples are the date that we receive the item and the date we open an item. Make sure that hair restraints are worn thought your shift. Review of the kitchen in-service training dated [DATE] revealed kitchen staff had been trained on food handling, including no eating in the food preparation areas and how to open food items. Review of the facility policy titled Employee Sanitation date approved [DATE] reflected, Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 3. Employee Cleanliness Requirements b. All employees must wear clean outer clothing. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces . e. Employees will not eat or drink in food storage and preparation areas, or in areas containing exposed food or unwrapped utensils, or where utensils arc cleaned or stored. 6. Use of Gloves a. Gloves are not a substitute for thorough and frequent hand washing. When using gloves, always wash hands before touching or putting on new gloves. c. Use single use gloves for one task. d . Change gloves: i. Between each food preparation task. ii. After touching items, utensils, or equipment not related to task. iii. After touching hair, face, or any other source of contamination. iv. When leaving food preparation area for any reason. vi. Every hour for all tasks taking longer than one hour. Review of the facility policy titled Food Storage revised [DATE] reflected: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 2. Refrigerators a. Keep fresh meat, poultry, seafood, dairy products, and most fresh fruit and vegetables in the refrigerator at an internal temperature of 41 For less . d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers a. Store all frozen meats, poultry, seafood, fruits and vegetables, and some dairy products, such as ice cream, in the freezer at a temperature that maintains the frozen state of the foods . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated . h. Place a thermometer inside freezers near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0 F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the freezer. i. Once frozen food has been thawed, it must be maintained at 41 F or less prior to cooking. Review of the facility policy titled Food Holding and Service date approved [DATE] reflected: Policy: The consultant dietitian will monitor the holding and service of food to ensure that all food served by the facility is of good quality and safe for consumption. All food will be held and served according to the state and Federal Food Codes. See Section 6 for Quality Assurance Monitor forms and schedule. The following guidelines should be followed. Guidelines: 1. All hot foods are served at a temperature of ? 140 F and all cold food at ? 40 F. The temperature is adjusted to account for the time the food will be held prior to service on the steam table and on the tray carts. 2. Foods are held prior to service for less than one hour, maintaining the temperatures noted above. Foods are covered to maintain temperatures except for foods that will be served crispy. 3. Food is placed on the steam table no more than 30 minutes prior to meal service. 4. If hot foods drop below 140 F, it is reheated to 165 F for a minimum of 15 seconds. 7. Temperatures of all hot foods and cold foods are taken at the beginning, middle, and end of tray service. Review of the facility's undated policy titled Foods Brought by Family/Visitors reflected: Policy Statement Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy Interpretation and Implementation 1. Family members and visitors are asked to inform nursing staff when foods are brought for a resident. 2. Foods brought by family/visitors for individual residents are not shared with or distributed to other residents. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. a. Non-perishable foods are stored in re-scalable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods are stored in re-scalable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. 6. The nursing staff will discard perishable foods on or before the use by date.

Based on observations, interviews, and record review the facility failed to treat residents with respect and dignity for one (Resident #11) of six residents reviewed for dignity. The facility failed to speak to Resident #11 in a way that promoted her dignity and self-worth. This failure could place resident at risk of a decline in their sense of dignity, level of satisfaction with life, and feeling of self-worth. The findings were: Review of Resident #11's quarterly MDS, dated [DATE], reflected a [AGE] year-old female originally admitted to the facility on [DATE] with a re-admitted [DATE]. Her diagnoses included high blood pressure, high cholesterol, diabetes mellitus (high blood sugar levels), depression, anxiety, senile degeneration of the brain, and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Resident #11 had a BIMS score of 12, indicating moderate cognitive impairment. She required setup or clean-up assistance with eating. Review of Resident #11's care plan dated last reviewed 11/18/2024 reflected the following: Observe/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Resident #11 had ADL Self Care Performance Deficit r/t impaired mobility. Will maintain current level of ADLs through the next review date. Setup or clean up assistance with: Eating. In an interview and observation on 02/18/2025 at 12:55 PM with Resident #11 she asked CNA C who was outside her room delivering lunch trays, what was being served for lunch. CNA C responded with, Looks like you're going to be having kitty litter today. Then sat Resident #11's tray on a table in her room and walked out. When the state surveyor asked Resident #11 how the comment made by CNA C made her feel. She stated that she did not really hear the comment, but that she would not have eaten the food if she was told that, and that the staff say way worse things to the residents when the state was not in the building. She stated she tried to not ask certain staff questions or for help because of how rude they talked to her. She stated that she would ask for help if she really needed it but only to the staff who didn't treat her like a bother and who did their jobs. In an interview on 02/19/2025 at 10:10 AM with the ADM he stated that it was not okay for a staff member to talk to a resident in the manner CNA C did to Resident #11 and he immediately went to speak with Resident #11. The ADM stated that there has not been a professional communication targeted in-service but that abuse in-servicing was routinely done and was most recently conducted earlier in the month. Review of facility's Resident Rights policy dated last revised February 2021 reflected, Employees shall treat all residents with kindness, respect, and dignity. 2. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. A dignified existence; d. Be treated with respect, kindness, and dignity; Review of facility's Identifying Types of Abuse policy dated last revised September 2022 reflected, As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. 1. Abuse of any kind against residents is strictly prohibited. 2. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. 3. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and support, and a facility-wide culture of compassion and caring. 4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. b. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. 2. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. 3. Examples of mental and verbal abuse include, but are not limited to: a. harassing a resident; b. mocking, insulting, ridiculing; c. yelling or hovering over a resident, with the intent to intimidate; d. threatening residents, including but not limited to, depriving a resident of care, or withholding a resident from contact with family and friends; and e. isolating a resident from social interaction or activities.

Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 3 of 8 residents (Resident's #112, #72, and #99's) reviewed for resident rights. The facility failed to ensure Resident's #112 and #99's call light was within reach on 02/18/25 and 02/19/25. The facility failed to ensure Resident #72's call light was within reach on 02/19/25. This failure could place residents at risk of needs not being met. Findings included: Record Review of Resident #99's face sheet dated 02/20/25 reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included pneumonia (an infection that that inflames air sacs, which may fill up with fluid, in the lungs), myocardial infarction (a condition when one or more areas of the heart muscle don't get enough oxygen), dysphagia (difficulty in swallowing), diabetes (a disease that result in too much sugar in the blood), and hypertension (a condition in which the force of the blood against the artery walls is to high). Record Review of Resident #99's MDS dated [DATE] reflected Resident #99 was dependent on staff for eating, toileting, bathing, and personal hygiene. MDS reflected Resident #99 had a BIMS score of 09 which indicated Resident #99 was moderately impaired. Record review of Resident #99's care plan dated 12/16/23, updated on 7/18/24 reflected: Resident had physical functioning deficit related to CVA with left sided weakness (hemiplegia). Interventions included call bell within reach. The care plan initiated 12/28/23 At risk for falls related to generalized weakness, impaired cognition, and safety awareness. Interventions included call light and personal items available and in easy reach or provide reacher. In observation on 02/18/25 at 10:23 AM Resident #99 was lying in bed resting quietly and had no signs of pain or distress. The resident did not respond when the state surveyor called his name. The residents call light was out of reach on the floor between the bed and wall. The resident was on EBP and had a peg tube (enteral tube inserted into the stomach). In an observation on 02/19/25 at 10:23 AM, Resident #99 was lying in bed resting. The residents call light was out of reach on the floor between the bed and wall. Record Review of Resident #112's face sheet dated 02/20/25 reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period), dysphagia (difficulty in swallowing), traumatic brain injury (an injury to the brain caused by an external force), sarcopenia (a type of muscle loss that occurs with aging and/or immobility), and encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). Record review of Resident #112's admission MDS dated [DATE] reflected Resident #112 was dependent on staff for eating, toileting, bathing, and personal hygiene. Record review of Resident #112's admission MDS dated [DATE] reflected Resident #112 had a BIMS score of 0 which reflected Resident #112 was severely cognitive impaired. Record review of Resident #112's care plan dated 12/03/24 reflected: Focus: Resident #112 had Impaired physical functioning related to: Cognitive loss, mobility impairment, self-care impairment, sarcopenia. Goals: Staff will assist Resident #112 to remain clean, dry, and comfortable through next review date. Interventions included: Call bell within reach. In an observation on 02/18/25 at 12:41 PM, Resident #112 was lying in bed with his blankets pulled up to his chest area. Resident #112 opened his eyes when his name was called but did not respond verbally. Resident #112 was on EBP and had a tracheostomy and peg tube. Residents call light was observed out of reach and was hanging to the left side of the head of the bed out of resident's reach. The resident was resting quietly and had no sign of pain or distress. In an observation on 02/19/25 at 10:15 AM, Resident #112 was lying in bed with his blankets pulled up to his chest area. The resident did not respond when his name was called. The residents call light was observed out of reach and was hanging to the left side of the head of the bed out of the resident's reach. The resident was resting quietly and had no sign of pain or distress. Record Review of Resident #72's face sheet dated 02/20/25 reflected the resident was an [AGE] year-old male admitted on [DATE]. His diagnoses included senile degeneration of the brain (a progressive decline in cognitive function that occurs with aging), spinal stenosis (an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots), dysphagia (difficulty in swallowing), and thoracic aortic aneurysm (the ballooning of the upper aspect of the aorta, above the diaphragm). Record review of Resident #72's quarterly MDS dated [DATE] reflected Resident #72 had a BIMS score of 15 which meant Resident #72 was cognitively intact. Resident #72 required supervision or touching assist for eating, and partial or moderate assist for toileting, bathing, and personal hygiene. Record review of Resident #72's care plan dated 11/13/23 reflected: Focus: Resident #72 had an ADL Self Care Performance deficit r/t impaired mobility. Goals: Resident #72 will improve current level of function in GGs, especially sit to lying, through the next review date. Interventions included: Encourage to use bell to call for assistance. In an interview and observation on 02/19/25 at 10:25 AM, Resident #72 stated he was doing well, and the staff treated him well. He stated he used the call light to call for help when needed and the staff responded to the call light pretty quickly usually. Resident #72 was sitting up in his wheelchair beside the bed and stated he could not get to his call light at that time because the CNA had just made the bed and she had put it where he could not reach it. Resident #72's call light was observed out of site and stuck in between the wall and bed, covered by blankets. The resident demonstrated with his hands and a reaching device that belonged to him that he could not reach the call light at that time. He stated if he needed help, he guessed he would go out into the hallway or yell for someone to come. In an interview on 02/19/25 at 10:17 AM, LVN A, stated Resident #112 was not able to move his arms or legs but he may have made a jerking movement every now and then. She stated Resident #112's call light should be within his reach at all times. LVN A went into Resident #112's room and saw that residents call light was hanging on the side of his bed out of his reach. She stated she did not feel that Resident #112 was capable of pressing the call button, but the call light was not in an appropriate place, and he could not have pressed the button if he tried. She stated she had been trained on call light placement and if a resident did not have their call light in reach, the resident could have fallen or may not have been able to call for help. In an interview on 02/19/25 at 10:27 AM, the ADON stated Resident #99 had the ability to use the call light. She stated Resident #99's call light should be within reach at all times. She stated she had been trained on call light placement. When asked what could happen if the resident did not have their call light in reach, she stated she wasn't sure what the state surveyor was asking. In an interview on 02/19/25 at 10:38 AM, CNA C, stated all residents call lights should be in reach at all times. CNA C entered Resident #72's room and observed the residents call light on the side of the bed stuck between the bed and the wall and covered by blankets. She stated Resident #72's call light was out of his reach at that time. She stated she had been trained on call light placement and if a resident's call light was out of reach, they could fall trying to get to the light or could not call for help. In an interview on 02/19/25 at 10:43 AM, CNA D stated all residents call lights should be in reach at all times. She stated she was trained on call light placement and if a resident did not have their call light within reach, it could have led to an accident. In an interview on 02/19/25 12:41 PM, CNA B, stated Resident #112 did not move around in his bed, but his call light should still be within reach. CNA B entered Resident #112's room and observed the resident's call light hanging to the left side of his bed. She stated Resident #112's call light was not where it should have been, and it was probably moved out of the way when the resident was changed. She stated she had been trained on call light placement and all resident's call lights should be within the resident's reach at all times. She stated if a resident's call light was out of reach, anything could happen, such as a resident could have fallen, hurt themselves, or have tried to walk without assistance, and they would not be able to call for help. In an interview on 02/20/25 at 09:52 AM, the ADM stated in most cases it was his expectation that all residents have their call lights within their reach. He stated some residents had requested that their call light be clipped to their curtain, and they had that care planned, and there were also some residents that were not able to use their call lights due to their condition. He stated for those that could not use their call lights, the staff made more frequent rounds and tried to anticipate their needs. He stated the staff were trained on call light placement. He stated if a resident could use the call light, they could probably still call out by yelling, but they may not have been able to call by using the call light. In an interview on 02/20/25 at 10:02 AM, the DON stated it was her expectation that all residents had their call lights within reach for those residents that could use them. She stated some residents wanted their call light clipped to their curtain and those residents had been care planned for that. She stated for those residents that could not use the call lights, the staff tried to anticipate the residents needs and made rounds on them more frequently. She stated staff had been trained on call light placement. She stated if a resident could use the call light and the call light was out of their reach, they may have had a need that was unmet. Record review of the facility policy titled Answering the Call Light and dated 2001 (revised July 2023) reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .

Based on observations, interviews, and record review, the facility failed to ensure that the resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for four of six residents (Resident #11, Resident #43, Resident #53, and Resident #108) whose care was reviewed. The facility failed to allow Residents #11, #43, #53, and #108 to enjoy the salad bar that was served in the dining room because they either preferred to eat in their rooms or were bed ridden. This failure could place residents at risk of diminished feelings of self-worth and/or diminished quality of life. Findings included: Observation on 02/18/2025 at 12:54pm in the facility's 1 of 2 dining rooms revealed a kitchen aide serving hot dogs out of a crock pot, topping it with chili, cheese, and optional onions. When residents were being brought into the dining room by staff, or walking into the dining room, the aide would ask them if they wanted onions on their chili cheese dogs, and how many they wanted. The residents in the dining room were served plates with chili cheese dogs with a side of potato chips. Once residents appeared to be finished, staff who were assisting in the dining room would ask if the residents were full, if they had enough to eat, if they wanted another chili dog, or if they wanted to go back to their room. No plates of food that contained the posted menu in the dining room were observed to be offered and/or served to any of the seated residents in the dining room. The trays being loaded onto carts to go to the halls were observed to only contain the facility posted menu items. Review of Resident #11's quarterly MDS, dated [DATE], reflected a [AGE] year-old female originally admitted to the facility on [DATE] with a re-admitted [DATE]. Her diagnoses included high blood pressure, high cholesterol, diabetes mellitus (high blood sugar levels), depression, anxiety, senile degeneration of the brain, and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Resident #11 had a BIMS score of 12, indicating moderate cognitive impairment. She required setup or clean-up assistance with eating. Review of Resident #11's care plan dated last reviewed 11/18/2024 reflected the following: Observe/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Resident #11 had ADL Self Care Performance Deficit r/t impaired mobility. Will maintain current level of ADLs through the next review date. Setup or clean up assistance with: Eating. In an interview on 02/18/2025 at 12:55 PM with Resident #11 she stated that she sometimes goes to the dining room to eat and sometimes chose to eat in her room. She said that if she goes to the dining room a different meal would be served than what was given to residents who eat in their room. She stated that she had to go to the dining room at lunch to find out what was being served and if she did not like it, she would go wait in her room for her tray. She said that she must go to the dining room to check because that special meal was only given to residents who go to the dining room, they would not bring it to the residents in their room. Review of Resident #43's quarterly MDS, dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), heart failure, high blood pressure, diabetes mellitus (high blood sugar levels), high cholesterol, lack of coordination, morbid obesity, pressure ulcer of right heel, and need for assistance with personal care. Resident #43 had a BIMS score of 12, indicating moderate cognitive impairment. He required supervision or touching assistance with eating, where the helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completed activity. Assistance may be provided throughout the activity or intermittently. Review of Resident #43's care plan dated last reviewed 02/18/2025 reflected Resident #43 was at risk for alteration in nutrition r/t high BMI and therapeutic diet. The dietary staff were to evaluate current dietary intake, eating habits, nutritional status, and review his food preferences, likes/dislikes. In an interview on 02/20/2025 at 11:15 AM with Resident #43 he stated that he mostly stayed in his room, and he ate his meals in his room because he did not like crowds. He was not aware that if residents go to the dining room, they get served something different than the meal that was on the menu. He said that if they were serving something he liked he would like to have the meal, but he did not want to go to the dining room, and he didn't know what special meal would be served. It would make him feel good if they served something he really enjoyed and brought it to his room. He stated he knew about the alternative menu but had no idea they served items like chili cheese dogs and chicken fajitas. Review of Resident #53's quarterly MDS, dated [DATE], reflected a [AGE] year-old female originally admitted to the facility on [DATE], with a re-admitted [DATE]. Her diagnoses included anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), high blood pressure, seizure disorder, unspecified abnormalities of gait and mobility, muscle weakness, and depression. Resident #53 had a BIMS score of 11, indicating moderate cognitive impairment. She was independent and required no assistance from a helper with eating. Review of Resident #53's care plan dated last reviewed 11/08/2024 reflected the following: serve diet as ordered, observe intake, and record every meal, regular diet, regular texture, regular consistency. In an interview on 02/20/2025 at 11:25 AM with Resident #53 she stated that she did not know that the facility had a special meal in the dining room, and she was not aware that chili cheese dogs and chips were served on 02/18/2025 in the dining room. She stated that if she knew special meals were served and she heard it was something she enjoyed eating, she would love to have that meal, but that she almost always ate in her room with her roommate. Review of Resident #108's comprehensive MDS, dated [DATE], reflected a [AGE] year-old man originally admitted to the facility on [DATE] with a re-admitted [DATE]. His diagnoses included paraplegia, iron deficiency, malnutrition, post-traumatic stress disorder, lack of coordination, contracture of muscle, hearing loss, pressure ulcer of the right hip, right hip open wound, and left hip open wound. Resident #108 had a BIMS score of 14 indicating intact cognition. He required supervision or touching assistance with eating. He was dependent on staff for all functional abilities (rolling in bed, sitting up, and transfers). Review of Resident #108's care plan dated last revised 11/08/2024 reflected Resident #108 had an ADL self-care performance deficit r/t limited ROM, musculoskeletal impairment, and pain. He was to be provided supportive care and assistance with mobility as needed. His diet and food texture were to be provided as tolerated and to be encouraged with food and fluid intake. In an interview on 02/20/2025 at 08:40 AM with Resident #108 he stated that he was not aware a special meal was served in the dining room and that it was not fair to people like him who were not able to go to the dining room. He stated he would have wanted to have chili cheese dogs and chips on 02/18/2025 as well as anything else that was offered that sounded appealing to him. He said it was not right for the facility to only serve it to residents who go to the dining room and not to offer it to residents in their rooms. In an interview on 02/19/2025 at 11:51 AM with the DM she stated that meals served in the dining room were not listed on the menu. Chili dogs, brisket, salad, baked potatoes, fajitas, taco soup, pulled pork potatoes, clam chowder soup, were not listed on the menu. It was like a side dish. She stated those don't need a menu or recipe. She was not aware of any policy. She knew all the resident's meal types and knew which residents could have which kinds of meal textures. The different food served in the dining room was an incentive to bring residents out of their rooms to get different food. The residents that eat in their rooms could not get this special meal. She created the idea and has been doing it for about 2 months. There was no process about it. In a follow up interview on 02/20/2025 at 9:54 AM with the DM she stated that she came up with the easy meal about 2-3 months ago and that residents must go to the dining room to have it because it was an incentive to get them to go eat in the dining room. She stated that the food served was not posted in the facility, and it was only served Monday through Friday due to there being more staff such as speech therapists who could sit in the dining room and watch any residents who may have an altered diet (such as mechanical soft, minced, and moist, puree) and want to try the special meal of the day. She stated that there was no policy or procedure regarding this easy meal. In an interview on 02/20/2025 at 11:29 AM with CNA E, who has worked at the facility for 2 years, stated that the special meals served in the dining room have been going on for a couple months and that sometimes the kitchen staff would tell the nursing staff what would be served. Then the nursing staff could tell the residents who were awake, but that did not always happen. She stated that the kitchen staff have been asked by nursing staff if residents who eat in their rooms could be brought those meals to which the kitchen staff have told them that those residents get what's on their tray. If they wanted the meal being served in the dining room, they could go to the dining room. CNA E stated that it was not right, and all residents should get the option to have that special meal because it could make residents feel left out. In an interview on 02/20/2025 at 01:13 PM, the ADM stated that the meal served in the dining room was set up as an appetizer, and that dietary staff would take it down the halls to residents who requested it. The ADM stated that the policy and procedure for food that is served was that multiple staff including speech therapists monitor in the dining room. Whoever was serving at the steam table had the serving list. He stated there wasn't a menu, and that resident's just know things were going to be new and different every day. The ADM stated the dietitian she knew about the meals. For residents who were primarily bed bound, he stated that residents talk about the meal and they will just know something is different. He said it is considered an appetizer bar and that residents still receive their trays. The ADM stated that all residents, no matter their abilities are allotted the same rights when it comes to food choices, and they have an always available menu that they can order from. In an interview on 02/20/2025 at 02:09 PM with CNA F she stated that she did not know how the special meal in the dining room worked and there was a lot of confusion amongst residents. The residents who stayed in their rooms would hear about other residents eating something different than what they received on their trays, and they ask how they could get that. She stated that the residents in their rooms were not offered the special meal by the kitchen staff, and that they have a right to enjoy the same foods. Review of facility's Resident Rights policy dated last revised February 2021 reflected, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence; b. Be treated with respect, kindness, and dignity; d. Be free from involuntary seclusion; Review of the facility's Holiday and Special Meals Policy dated October 1, 2018, reflected, The facility believes that the quality of life for its residents should be maximized whenever possible. On holidays or special occasions, all residents will be served the same menu provided the physician has approve diet liberalization on such occasions. Procedure: 1. Upon admission, the physician will indicate whether the resident may have a liberalized diet on special occasions. Approval will be noted on the resident's order sheet. 2. The menu for the holiday or special occasion will be planned during the resident council meeting or other meeting where resident input can be obtained. 3. The consultant NDTR or RDN will review and approve the holiday or special occasion menu for adequacy and appropriateness for the resident population. The menu will be extended by the dietitian/NDTR for all diets offered at the facility. 4. For any resident not approved for a liberalized diet, the dietitian/NDTR will develop an extension of the holiday or special occasion menu to allow the resident to have as many items on the menu as possible. 5. Texture modifications, such as ground meats or pureed, will be prepared for residents requiring texture modification. Thickened liquids will be provided as ordered by the physician.

Based on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences for 4 of 12 residents (Resident #9, Resident #11, Resident #43, and Resident #53) reviewed for food preferences. The facility failed to ensure Resident #9's lunch tray excluded gravy, in accordance with her dislikes which were listed on her meal ticket, on 02/20/2025 when the facility served Resident #9 two hamburger patties covered in brown gravy. The facility failed to ensure Resident #11's lunch tray included margarine and sweet and low, in accordance with her meal ticket as well as her preferences, (which were not listed on her meal ticket), on 02/18/2025, 02/19/2025, and 02/20/2025 and failed to include her coffee or tea on her lunch tray on 02/19/2025. The facility failed to ensure Resident #43's breakfast tray excluded oatmeal, in accordance with his dislikes that were not listed on his meal ticket on 02/20/2025 and failed to include margarine on his lunch trays on 02/18/2025, 02/19/2025, and 02/20/2025 in accordance with his meal ticket as well as his preferences (which were not listed on his meal ticket). The facility failed to ensure Resident #53 received an alternate meal of hamburgers for lunch on 02/18/2025, 02/19/2025, and 02/20/2025 in accordance with her meal substitute request form. These failures placed residents at risk of poor intake, possible weight loss, and diminished quality of life. Findings included: Review of Resident #9's quarterly MDS, dated [DATE], reflected a [AGE] year-old female originally admitted to the facility on [DATE] with a re-admitted [DATE]. Her main diagnoses included quadriplegia (paralysis of all four limbs and the torso), traumatic brain injury, epilepsy (seizure disorder), anxiety, and dysphagia (difficulty swallowing). Resident #9 had a BIMS score of 15, indicating no cognitive impairment. Her speech was unclear. She was dependent and required total assistance with eating. Resident had a regular diet. Review of Resident #9's care plan dated 12/12/2024 reflected resident was dependent in all activities of daily living due to quadriplegia. The resident needed staff to assist with feeding and interventions included: Observe/document/report PRN any symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Resident #9 had a potential nutritional problem due to anemia and impaired mobility. Interventions included: Determine individual likes and dislikes .and provide, serve diet as ordered. Observation and interview on 02/18/2025 at 01:21 PM in resident's room revealed Resident #9 was being served lunch. Resident #9's meal ticket listed, [NAME] sugar glaze ham as the main item and listed preferences of no gravy, no sauce. Resident #9's lunch plate had two beef hamburger patties covered in brown gravy. In an interview, Resident #9 stated she did not like sauce nor gravy because it was too salty but had no diet restrictions. Resident #9 stated she was not okay eating the hamburger patties and stated, But no one cares. She stated she would not eat the hamburger patties because they had gravy on them but would eat the other items offered. In an interview on 02/18/2025 at 02:18 PM Resident #9 stated lunch was shitty. She did not eat the hamburger patties covered in gravy. She stated staff did not care and did not pay attention to things like her meal ticket. Resident #9 stated she knew she could ask for an alternative but did not ask for one. Resident #9 stated she had food available in the room if she got hungry. Review of Resident #11's quarterly MDS, dated [DATE], reflected a [AGE] year-old female originally admitted to the facility on [DATE] with a re-admitted [DATE]. Her diagnoses included high blood pressure, high cholesterol, diabetes mellitus (high blood sugar levels), depression, anxiety, senile degeneration of the brain, and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Resident #11 had a BIMS score of 12, indicating moderate cognitive impairment. She required setup or clean-up assistance with eating. Review of Resident #11's care plan dated last reviewed 11/18/2024 reflected the following: Observe/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Resident #11 had ADL Self Care Performance Deficit r/t impaired mobility. Will maintain current level of ADLs through the next review date. Setup or clean up assistance with: Eating. No review of food preferences, likes/dislikes were noted on the care plan. Observation on 02/18/2025 at 12:54 PM in resident's room revealed Resident #11 had a meal ticket on her lunch tray with margarine printed as one of the menu items, but margarine was not on her tray. Observation on 02/19/2025 at 01:14 PM in resident's room revealed Resident #11 had a meal ticket on her lunch tray with margarine printed as one of the menu items, but margarine was not on her tray. Observation on 02/20/2025 at 01:10 PM in resident's room revealed Resident #11 had a meal ticket on her lunch tray with margarine printed as one of the menu items, but margarine was not on her tray. In an interview on 02/18/2025 at 12:55 PM with Resident #11 she stated that she never gets butter (margarine) on her tray. She always asked the aide who brought the tray to go get her butter but that they just set the tray down and leave her room and don't come back until they were taking the trays away. She stated that some of the aide's act bothered by having to do anything for the residents and it makes her not want to ask for assistance. She stated that she liked to have sweet and low with her tea, but they often don't bring that either even thought her meal ticket says it should be on her tray. Review of Resident #43's quarterly MDS, dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), heart failure, high blood pressure, diabetes mellitus (high blood sugar levels), high cholesterol, lack of coordination, morbid obesity, pressure ulcer of right heel, and need for assistance with personal care. Resident #43 had a BIMS score of 12, indicating moderate cognitive impairment. He required supervision or touching assistance with eating, where the helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completed activity. Assistance may be provided throughout the activity or intermittently. Review of Resident #43's care plan dated last reviewed 02/18/2025 reflected Resident #43 was at risk for alteration in nutrition r/t high BMI and therapeutic diet. Dietary staff were to evaluate current dietary intake, eating habits, and nutritional status, review his food preferences, likes/dislikes. Observation on 02/18/2025 at 12:50 PM in resident's room revealed Resident #43 had a meal ticket on his lunch tray with margarine printed as one of the menu items, but margarine was not on his tray. Observation on 02/19/2025 at 01:10 PM in resident's room revealed Resident #43 had a meal ticket on his lunch tray with margarine printed as one of the menu items, but margarine was not on his tray. Observation on 02/20/2025 at 01:07 PM in resident's room revealed Resident #43 had a meal ticket on his lunch tray with margarine printed as one of the menu items, but margarine was not on his tray. In an interview on 02/18/2025 at 10:22 AM with Resident #43 he stated that he had food preferences but that the facility did not honor them. He stated that he did not like oatmeal, but he gets it anyway on days oatmeal was served. He said that he regularly refused the oatmeal by pushing it to the side of his tray and telling the aides when they pick up his tray. He has told his aides he did not like it, as well as other items he could not specify at the time. He stated they often get bread with lunch but that he never gets butter (margarine) with it when the meal ticket says it was supposed to have it. He stated that the aides just bring the trays and leave. He stated that he did not like to use his call button often because it took a long time for the aides to come back and they did not want to get small things for them, like butter. Review of Resident #53's quarterly MDS, dated [DATE], reflected a [AGE] year-old female originally admitted to the facility on [DATE], with a re-admitted [DATE]. Her diagnoses included anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), high blood pressure, seizure disorder, unspecified abnormalities of gait and mobility, muscle weakness, and depression. Resident #53 had a BIMS score of 11, indicating moderate cognitive impairment. She was independent and required no assistance from a helper with eating. Review of Resident #53's care plan dated last reviewed 11/08/2024 reflected the following: serve diet as ordered, observe intake, and record every meal, regular diet, regular texture, and regular consistency. No review of food preferences, likes/dislikes were noted on the care plan. Observation on 02/18/2025 at 12:47 PM in resident's room revealed Resident #53 had the lunch meal that was posted on the facility menu, but she had requested a burger for lunch. Observation on 02/19/2025 at 01:07 PM in resident's room revealed Resident #53 had the lunch meal that was posted on the facility menu, but she had requested a burger for lunch. Observation on 02/20/2025 at 01:03 PM in resident's room revealed Resident #53 had the lunch meal that was posted on the facility menu, but she had requested a burger for lunch. In an interview on 02/18/2025 at 12:47 PM with Resident #53 she stated that she almost always wants a burger for lunch, but she never gets it unless her FM brings one to her. She said that her FM will come to the facility and bring her a burger but also fill out some papers and take them to the kitchen so that the resident could get burgers but that she did not get them. In an interview on 02/19/2025 at 01:42 P.M with a FM of Resident #53 she stated that Resident #53 did not always like what was offered to eat at the facility. The FM visits the resident once a week and will fill out a form for the resident to receive burgers for lunch, but when the FM calls the resident to ask if she received a burger for lunch, the resident often says that she did not get the burger on her lunch tray. The FM will bring the resident a burger for lunch on the days she visited because the facility will not honor her food preferences for lunch. Observation on 02/18/2025 at 12:50 PM in the kitchen revealed the kitchen staff ran out of brown sugar glazed ham that was listed on the menu for lunch. In an interview on 02/18/2025 at 01:26 PM CNA E, stated she was going to assist Resident #9 with feeding. CNA E acknowledged that the meal ticket said, no gravy, no sauce and the hamburger patties were covered in gravy. CNA E stated that usually she would go tell the nurse, but Resident #9 had food in her room and therefore, would proceed with feeding the resident the other items on the tray and not inform the nurse. In an interview on 02/19/2025 at 11:51 AM the DM stated resident's meal preferences were listed on meal tickets and staff should read and put the correct items on the tray to honor food preferences. The DM stated the cooks, and she were responsible for checking meal tickets to ensure accuracy of residents' preferences. When asked about a resident receiving hamburger patties covered in gravy on 02/18/2025 who had a preference of no gravy, no sauce listed on a meal ticket, the DM stated that the kitchen ran out of the glazed ham and hamburger patties were served as a substitution. The DM responded, We really dropped the ball yesterday and no, that would not meet my expectation. An interview was attempted on 02/20/2025 at 09:20 AM, with CK F regarding residents' meal preferences; however, the employee had been terminated and no longer worked at the facility. In an interview on 02/20/2025 at 09:20 AM, the DA stated that she had received orientation and in-service trainings regarding her job duties. She worked the tray line, set up meal trays, and checked meal tickets for accuracy. During an interview on 02/20/2025 at 09:54 AM, the DM stated that residents could put in orders for alternative meals if they did not want what was being served. She stated that alternate meal requests must be turned in by a certain time of day and if they were not turned in the resident would not get an alternate meal. She said that Resident #53 would put the wrong dates on her forms, if the DM was working, she would notice the wrong date and honor the alternate request but if she was not working than more than likely the resident would not get the alternate meal because the person reading the request would think it's for the date written. She stated that no one goes to check with the resident to see what date was meant to be written. No alternate meal request forms were able to be provided to the state surveyor. In a telephone interview on 02/20/2025 at 11:10 AM the dietitian stated that she visited the kitchen once a month and audited the tray line, among other things, for tray line accuracy, which had been an ongoing issue. The dietitian stated she had provided training on this and other topics. During an interview on 02/20/2025 at 01:13 PM, the ADM stated that all residents could choose from the always available menu and that their preferences should be honored. Review of the kitchen in-service training dated 09/30/2024 reflected kitchen staff had been trained on the topic of tray line and checklists for menu compliance. Review of the facility policy titled Tray Line Service approved 12/01/2011 reflected, The consultant dietitian will monitor the tray line to ensure that diets are served accurately and in the correct portions and that patient/resident preferences are met. The following guidelines should be followed. 3. Staff on the tray line check each resident's tray card to ensure that dietary preferences and dislikes are honored, and appropriate substitutions provided. 4. Each tray is checked by the tray line personnel to ensure that the diet is served as ordered, the portion size of each item is correct, and preferences are met. The Dietary Manager conducts a tray line audit once each week for each meal to ensure that diets are served correctly and to identify any training needs. Review of the facility's Alternate Food Choices and Substitutions and Honoring Preferences policy date approved October 1, 2018, reflected, The facility believes that adequate nutrition is essential to each resident's well-being and good health. An alternate entree and vegetable will be offered at each meal. The facility also supports resident choice and allowing residents to choose foods by honoring their food preferences. Other substitutions will also be available in the event a resident does not choose the main meal or the alternate. 1. Residents will be informed on admission that there is an alternate for each meal and will also be informed of substitutions which are available on a daily basis. 2. The Nutrition & Food service Manager or designee will obtain the resident's food preferences upon admission and record preferences in the tray card system. 3. Residents will be served the main menu at each meal unless they request the alternate. 4. If a resident's preferences indicate they dislike the main meal, the alternate will be served unless the resident requests a substitution. 5. Nursing staff will observe the residents at mealtime. Any resident not eating will be offered the alternat meal or a substitute from the items available in the kitchen. The items offered must be compatible with any dietary restrictions or texture modifications. 6. Nursing staff will inform the Nutrition & Food service department of the resident's request. The Nutrition & Food service department will prepare the alternate or substitution and give it to Nursing to serve the resident. 7. The Nutrition & Food service Manager will be informed by the Nutrition & Food service staff of the resident's request so that the resident's preferences can be updated. 8. If a resident consistently refuses meals, alternates, and substitutions for three or more meals, the Nutrition & Food service Manager will be notified. The Nutrition & Foodservice Manager will visit the resident to determine if a change in diet or preferences is appropriate. 50176

Based on observations, interviews, and record review the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) for 1 of 4 residents (Resident #231) reviewed for ADL abilities. Resident #231's glasses were dirty and had built-up grime present to both lenses on 02/19/25. This deficient practice could place residents who required assistance at risk for not receiving care and services to meet their needs and avoid ADL decline. Findings included: Record Review of Resident #231's face sheet dated 02/20/25 reflected the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). Record review of Resident #231's uncompleted admission MDS dated [DATE] reflected Resident #231 had a BIMS score of 05 which reflected Resident #231 was severely cognitively impaired. The MDS reflected Resident #231 used corrective lenses (contacts, glasses, or magnifying glass). Record review of Resident #231's care plan dated 02/18/25 reflected: Focus: Resident #231 was At risk for falls/injury r/t history of falls, poor safety awareness. Goals: Resident #231 will be free from injury r/t falls through next review date. Interventions included: Assess for adaptive equipment needs. In an interview on 02/19/25 at 09:55 AM, Resident #231 stated she was doing ok. She stated the staff treated her well and she felt safe in the facility. Resident #231's glasses were dirty and had built-up grime present to both lenses. Resident stated nobody cleaned her glasses but her and the nurses and the glasses had not been cleaned in a long time. Resident #231 stated she could still see out of her glasses but did not know if she would have been able to see better if they had been cleaned. Resident #231 removed her glasses when speaking to the state surveyor and only touched the frames of the glasses. The resident's hands were clean and did not have any visible dirt or matter present that would have transferred to the glasses at that time. In an interview on 02/19/25 at 10:01 AM, the OT stated she did not know who was ultimately responsible for cleaning the resident's glasses but when the resident's came to therapy, she tried to keep the resident's glasses as clean as possible. She stated Resident #231's vision could have been impaired by having dirty glasses and that she did not think Resident #231's glasses were as dirty on the previous day. In an interview on 02/19/25 at 10:38 AM, CNA C, stated the residents' glasses were supposed to be checked and cleaned daily and it should have been done every morning. She stated she was trained on keeping residents belongings, which included glasses, cleaned and if a resident's glasses were dirty, it could have increased resident's risk of having a fall. In an interview on 02/19/25 at 10:43 AM, CNA D stated it was the CNA's responsibility to clean resident's glasses. She stated she automatically knew to clean the resident's glasses and dentures and things like that. She stated she went through that training with her CNA clinicals and anyone taking care of the residents should know to do that. She stated if a resident wore glasses and the glasses were dirty, the resident may not be able to see well. In an interview on 02/20/25 at 09:52 AM, the ADM stated that resident's glasses should be cleaned when they were dirty or when the resident asked, but there was no policy that said the glasses should be cleaned daily. He stated if a resident had dirty glasses, it could cause irritation for the resident. In an interview on 02/20/25 at 10:02 AM, the DON stated resident's glasses should be cleaned as needed and if they were visibly dirty. She stated staff were trained on keeping the resident's glasses cleaned for those that could not do it themselves. She stated the expectation was if a resident could not meet their own needs which regarded their personal things or other things, staff would meet those needs for the residents. She stated if a resident's glasses were dirty and they could not see through them clearly, it could cause a nuisance for the resident. Record review of facility policy titled Activities of Daily Living (ADLs), Supporting dated 2001 revised March 2018, reflected Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: I. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. b. Unavoidable decline may occur if he or she: (1) Has a debilitating disease with known functional decline; (2) Has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; 2. Appropriate care and services will be provided for residents who are unable to cany out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); 6. Intervention to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice . Record review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment dated 2001 and revised September 2022 reflected Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation: b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact sk.in (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. (Note: Some items that may come in contact with non-intact skin for a brief period of time [e.g., hydrotherapy tanks, bed side rails] are usually considered non-critical surfaces and are disinfected with intermediate-level disinfectants.) c. non-critical items are those that come in contact with intact skin but not mucous membranes. (I) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. (2) Non-critical environmental surfaces include bed rails, bedside tables, etc. (3) non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use, and disposal). a) Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Examples of low-level disinfectants include EPA- registered hospital disinfectants with an HBV and HIV label claim. Low-level disinfection is generally appropriate for most non-critical equipment. b) Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. EPA-registered hospital disinfectants with a tuberculocidal claim are intermediate-level disinfectants. Intermediate-level disinfection is considered for non-critical equipment that is visibly contaminated with blood. However, a low-level disinfectant with a label claim against HBV and HIV may also be used. 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). A. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals). In an interview on 02/19/25 at 09:55 AM, Resident #231 stated she was doing ok. She stated the staff treated her well and she felt safe in the facility. Resident #231's glasses were dirty and had built-up grime present to both lenses. Resident stated nobody cleaned her glasses but her and the nurses and the glasses had not been cleaned in a long time. Resident #231 stated she could still see out of her glasses but did not know if she would have been able to see better if they had been cleaned. Resident #231 removed her glasses when speaking to the state surveyor and only touched the frames of the glasses. The resident's hands were clean and did not have any visible dirt or matter present that would have transferred to the glasses at that time. In an interview on 02/19/25 at 10:01 AM, the OT stated she did not know who was ultimately responsible for cleaning the resident's glasses but when the resident's came to therapy, she tried to keep the resident's glasses as clean as possible. She stated Resident #231's vision could have been impaired by having dirty glasses and that she did not think Resident #231's glasses were as dirty on the previous day. In an interview on 02/19/25 at 10:38 AM, CNA C, stated the residents' glasses were supposed to be checked and cleaned daily and it should have been done every morning. She stated she was trained on keeping residents belongings, which included glasses, cleaned and if a resident's glasses were dirty, it could have increased resident's risk of having a fall. In an interview on 02/19/25 at 10:43 AM, CNA D stated it was the CNA's responsibility to clean resident's glasses. She stated she automatically knew to clean the resident's glasses and dentures and things like that. She stated she went through that training with her CNA clinicals and anyone taking care of the residents should know to do that. She stated if a resident wore glasses and the glasses were dirty, the resident may not be able to see well. In an interview on 02/20/25 at 09:52 AM, the ADM stated that resident's glasses should be cleaned when they were dirty or when the resident asked, but there was no policy that said the glasses should be cleaned daily. He stated if a resident had dirty glasses, it could cause irritation for the resident. In an interview on 02/20/25 at 10:02 AM, the DON stated resident's glasses should be cleaned as needed and if they were visibly dirty. She stated staff were trained on keeping the resident's glasses cleaned for those that could not do it themselves. She stated the expectation was if a resident could not meet their own needs which regarded their personal things or other things, staff would meet those needs for the residents. She stated if a resident's glasses were dirty and they could not see through them clearly, it could cause a nuisance for the resident. Record review of facility policy titled Activities of Daily Living (ADLs), Supporting dated 2001 revised March 2018, reflected Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: I. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. b. Unavoidable decline may occur if he or she: (1) Has a debilitating disease with known functional decline; (2) Has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; 2. Appropriate care and services will be provided for residents who are unable to cany out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); 6. Intervention to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice . Record review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment dated 2001 and revised September 2022 reflected Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation: b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact sk.in (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. (Note: Some items that may come in contact with non-intact skin for a brief period of time [e.g., hydrotherapy tanks, bed side rails] are usually considered non-critical surfaces and are disinfected with intermediate-level disinfectants.) c. non-critical items are those that come in contact with intact skin but not mucous membranes. (I) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. (2) Non-critical environmental surfaces include bed rails, bedside tables, etc. (3) non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use, and disposal). a) Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Examples of low-level disinfectants include EPA- registered hospital disinfectants with an HBV and HIV label claim. Low-level disinfection is generally appropriate for most non-critical equipment. b) Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. EPA-registered hospital disinfectants with a tuberculocidal claim are intermediate-level disinfectants. Intermediate-level disinfection is considered for non-critical equipment that is visibly contaminated with blood. However, a low-level disinfectant with a label claim against HBV and HIV may also be used. 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). A. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals).

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological's were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for two of five medication carts observed in that: Medication carts #1 and #2 were left unattended and unlocked. This failure could allow residents, staff and visitors unsupervised access to prescription and over-the-counter medications. Findings include: Medication Cart #1: An observation on 09/10/20224 at 5:10 am revealed Medication cart # 1 in Hall-B was against a wall across from the nurses' station, with the drawer's facing outward. The medication cart was unlocked and unsupervised. There were no residents and no staff within sight. Observation of the contents of the drawers revealed they contained prescription and over-the-counter medications. In an interview on 09/10/20224 at 5:12 am, LVN-A stated she had recently gotten something from the cart and forgot to lock it. The cart remained opened as LVN-A began to walk down the hall. In an interview on 09/10/20224 at 6:20 am, LVN-A stated the medication cart should have been locked. When asked about potential negative outcomes for residents she said they could take unprescribed medications and have severe reactions. Medication Cart #2: An observation on 09/10/20224 at 5:15 am revealed Medication cart # 2 in Hall-A was against a wall across from the nurses' station, with the drawer's facing outwards. The medication cart was unlocked and unsupervised. Two residents were sitting in the day room across from the nurses' station and multiple staff members navigating in, out and around the nurses' station. Observation of the contents of the drawer's revealed they contained prescription and over-the-counter medications. In an interview on 09/10/20224 at 5:20 am, LVN-B stated medication carts should be locked, unless they were being used. When asked about potential negative outcomes for residents, she said the residents could have had severe allergic reactions to medications, including death. In an interview on 09/10/2024 at 11:15 am, the DON stated the expectation was that medication carts should have been locked unless it was being used at that time. The drawers should have been faced towards the wall or inward, in the doorway of the resident's room. When asked about potential negative outcomes for residents, she said residents could have had minor allergic reactions to medications or it could have been fatal. In an interview on 09/10/2024 at 11:15 am, the ADM stated the expectation was for the medication and treatment carts to be locked when not in use. When asked about potential negative outcomes for residents, he said, Nothing could have happened, or something could have happened. He clarified that residents could have minor or severe reactions to medications and medications could have been taken from the cart. Record review of the facility's policy titled Security of the Medication Cart, 2001 MED-PASS, Revised April 2007, reflected: Policy Statement: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation: 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with the doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurse's station or inside the medication room.

Based on interviews and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of ten residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement and utilize facility abuse, neglect, exploitation, or misappropriation - reporting and investigating policies when they did not report to local, state, and federal agencies (as required by current regulations) allegations sent by a LPN via text message to the administrator. In the text, the LPN revealed she believed that Resident #2 ejaculated on Resident #1. The facility failed to identify and assess all possible incidents of abuse and investigate and report all allegations of abuse within timeframes required by federal requirements. This failure placed residents at risk of undetected abuse, trauma, and/or decline in feelings of safety and well-being or psychosocial harm. Findings included: Review of Resident #1's face sheet dated 08/21/24 reflected a [AGE] year-old male, in the facility secured unit, who was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included epileptic seizures, disorder of psychological development, cognitive communication deficit, and severe intellectual disabilities. Review of Resident #1's quarterly MDS assessment, dated 06/15/24, reflected a BIMS was not conducted because the resident was rarely/never understood, indicating a severe cognitive impairment. His cognitive skills for daily decision making were severely impaired, and he never/rarely made decisions. Section GG - functional abilities and goals was not completed with the exception of impairment on both sides both upper and lower extremities. Review of Resident #1's quarterly care plan reflected the following: A focus, revised on 11/01/19, that reflected Resident #1 had been identified as PASRR positive related to an intellectual disability and related condition of epileptic seizures. A focus revised on 08/09/23 reflected Resident #1 forgot things and had no sense of safety awareness or dignity issues with an intervention dated 10/15/22 to help Resident #1 maintain dignity. A focus revised on 08/09/23 reflected Resident #1 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #1 had little or no activity involvement due to his cognitive deficits. A focus revised on 11/05/18 of activities of daily living performance deficit related to impaired mobility and cognition. A focus revised on 11/30/23 reflected Resident #1 was non-verbal and yell off and on throughout the day. He yelled, clapped, and swayed his head back and forth as he wandered through hallways. Resident #1 had a history of sitting in laps of other residents and staff and he frequently chewed on his hands. Due to these behaviors, he was at risk for experiencing aggressive behaviors from his peers on the unit. A focus revised on 11/05/19 reflected Resident #1 had a communication problem related to intellectual disabilities, Aphasia (a condition in which the eye lacks a lens) with an intervention dated 11/05/18 to observe/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. A focus revised on 10/18/23 reflected Resident #1 received anti-anxiety medications for anxiety. A focus revised on 11/05/19 reflected Resident #1 received antidepressant medication for behaviors and insomnia. A focus revised on 01/09/24 reflected Resident #1 had a psychosocial well-being problem potential related to impaired cognition, severe and diagnosed intellectual and developmental disabilities. A focus revised on 06/27/22 reflected Resident #1 had impaired visual function related to impaired vision. Admitting hospital paperwork stated he was legally blind. A focus initiated on 08/20/24, the date the state entered the facility to investigate the complaint, revealed Resident #1 had a behavior problem r/t wipe drool and mucus on his clothing with an intervention dated 08/20/24 to clean resident hands/face and clothing as needed. Review of Resident #2's face sheet dated 08/20/24 reflected a [AGE] year-old male, in the facility secured unit, who was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included abnormal radiologic findings on diagnostic imaging of renal other diagnosis pelvis, ureter, or bladder chronic obstructive pulmonary disease with (acute) exacerbation and mild cognitive impairment of uncertain or unknown etiology. Review of Resident #2's quarterly MDS assessment, dated 05/24/24, reflected a BIMS score of 9 indicating Resident #2 was cognitively moderately impaired. Section E - Behavior potential indicators of psychosis reflected delusions (misconceptions or beliefs that are firmly held, contrary to reality). Behavioral symptom - presence & frequency behavior of this type occurred 1 to 3 days revealed other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Functional limitation in range of motion reflected no limitations in upper extremity (shoulder, elbow, wrist, hand) or lower impairment (lower extremity hip, knee, ankle, foot) and mobility devices wheelchair. Review of Resident #2's quarterly care plan reflected the following: A focus, revised on 03/08/24, that reflected Resident #2 had a potential for impaired cognition related to neurological symptoms of metabolic encephalopathy (a neurological disorder that occurs when a chemical imbalance in the blood affects the brain) with intervention dated 03/08/24 to monitor/document /report to medical doctor any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status and 03/08/2024 review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. A review of the care plan did not reveal a focus or interventions regarding Resident #2 bleeding when he urinates or bleeding at any other time. A record review on 08/20/24 of anonymous complaint in the Information Portal, an online system for submitting long-term care licensure applications and health care regulation Architectural Review requests, under the care areas of administration/personnel and resident/patient/client abuse. The complaint reflected, the complainant stated on 08/15/2024, or 08/16/2024, resident first name unknown (Resident #2) pulled out his penis and ejaculated on (Resident #2). The incident occurred on the facility's secured unit. Reportedly, the incident was reported by the facility's staff; however, administrator erased the report from the facility's system. The complainant would like for the facility to be investigated due to the allegations reported in this intake. Review of text message, undated, from the LPN to the administrator reflected, so I believe Resident #2 has a ejaculated on Resident #1 I am sending pictures his brief was dry inside his penis has no fluids at all bottom not penetrated sorry trying to be thorough Resident #1 has not been sleeping well for a while especially tonight. So I moved Resident #1 back with [another resident] call me back please. Review of photograph, provided to investigator by the LPN, of an incident report #831 for Resident #2 that was stricken dated 08/11/24 revealed; strike out was dated 08/12/24 strike out reason - data entry error strike out done by DON Description: Resident's roommate was in bed and was checked and changed and an unknown substance/secretion was observed on the outside of his brief. The inside of the brief was dry, and no secretions noted in brief. Resident was the only other male in the room and was observed by this LPN sitting in a chair near roommate. Roommate #1 is nonverbal. Resident unable to give description. Immediate action taken - Resident #2 was moved to another room pending outcome of incident. Administrator called and DON also notified. Injury type - no injuries observed at time of incident. In an interview on 08/20/24 at 12:15 pm with the LPN revealed she was very upset about the whole incident because she thought there was abuse and the incident should have been investigated. She revealed it happened on 08/11/24 at around 10:00pm. She revealed the CNA was doing rounds and the CNA asked her to look at something. The CNA brought her Resident #1's adult brief. The brief had a fluid substance on it. The CNA asked the LPN what she thought it was and the LPN said both the CNA and the LPN thought the substance on the brief looked like semen. The LPN took photos asked the CNA to put it in a bag to show the DON. The LPN revealed the SC/CNA came by and they asked her what she thought the substance was and the LPN said the SC/CNA also thought it was semen. The LPN said she texted her administrator and called both the administrator and the DON and sent them photos of the substance on the brief. The brief was left in a bag for the DON to see. The LPN revealed she moved Resident #2 into a room with another roommate because she was concerned about Resident #1 being abused because of the substance found on the brief. She revealed Resident #1 is a good sleeper, but he did not sleep well that evening. She revealed the Administrator, who was the abuse and neglect coordinator, did not ever talk to her about the incident. She said the DON called her back at 6:00 am the following morning and the DON said the substance could be spit and the substance was on the outside of the brief. The LPN said that the DON said she did not think it was semen and they could not prove that it was semen and they needed to let it go. The DON told the LPN to throw the brief out. The LPN revealed she felt the situation should have been investigated. When the LPN was asked if she told the DON that she did not feel there was any abuse she said she had always felt that Resident #1 was abused and that was why she moved Resident #2 out of the room, to keep Resident #1 safe. The LPN revealed that Resident #2 had previously not displayed any sexual behaviors and Resident #1, to her knowledge, had never masturbated. The LPN revealed that the DON, struck out her incident report. The LPN revealed that when the DON struck out her incident report, she was upset because they were not going to investigate the incident. In an interview on 08/21/24 at 11:05 with SC/CNA she revealed she was not working on the secured unit on 08/11/24. She was called over (unknown who called her over) and she was asked to look at a brief. She revealed she could not specify what the substance was on the brief, but said it had a strong order and it was a clear substance, it looked more like saliva. She said the LPN and the CNA expressed concerns about interaction between Resident #2 and Resident #1 because it seemed farfetched. She had worked on the secured unit consistently and Resident #2 urinates a lot and there was blood in his urine and anything that comes out of Resident #2 had blood on it. She described the substance on the brief as clear with a strong foul order. It was not milky white, and it was bubbly and looked like it had food particles in it. She did not feel like there was abuse because Resident #1 did not seem stressed. She revealed she had worked with Resident #1 for almost three years, and he drools a lot, and he does smear it. Where it is smeared depended on where his hand landed. She did not give a written signed statement about her observation. The DON and Administrator spoke to her about it. Staff rounds every two hours, and no resident was being looked at continuously. The overnight staffing consists of one nurse and one CNA. The abuse coordinator was responsible for the investigation of any reported abuse and neglect. In an Interview on 08/20/24 at 1:08 pm with the Administrator revealed he was flying back from a trip and he was half asleep and when he landed. He said the pictures of the substance on the brief and the text from the LPN stating she believed Resident #2 ejaculated on Resident #1 came over his phone. The Administrator revealed that Resident #1 slobbered and wiped his nose a lot. He revealed he gave the investigation to the DON because she was the clinical lead. He said the DON revealed to him that from a clinical standpoint she did not see any issue with the substance on the brief. She stated that because none of the staff witnessed the alleged incident happen and because the DON did not feel like the LPN was making an allegation of abuse and/or neglect, they did not report the incident. When asked if Resident #1 was assessed, the administrator said he was assessed by the LNP, and she gave the report verbally, but it was not documented. The Administrator revealed there was no documentation regarding the alleged incident except for three typed statements. One signed statement from the administrator, one typed summary of an interview with the LPN, and one typed summary of a telephone interview of the SC/CNA. The summaries of the verbal interviews with the LPN and SC/CNA were signed by the DON. The investigation also included a statement that attempts were made to reach the CNA by phone, but there were unsuccessful. The administrator confirmed that the CNA still worked at the facility PRN, but he did not know if she had been to work at the facility after the incident. When asked if he could find out if she had worked since the incident, the administrator did not inform the investigation. In an interview on 08/21/24 at 3:01 with the DON she revealed she received training on how to conduct abuse and neglect investigations and in this training, she was taught facilities had to report any suspicion of abuse and neglect. She stated she was aware of the facility policies and procedures. She said the LNP never said to her she felt like Resident #1 had been abused, there was no proof that Resident #2 had been on Resident #1's side of the room, no one observed him standing over Resident #1 or observed Resident #2 touching Resident #1. She revealed that Resident #2 has bladder cancer and bleed a lot when he urinated. She revealed that housekeeping had called it to her attention because Resident #2's bathroom looked like a murder scene. Because there was no blood visible in the substance on the brief, she did not feel Resident #2 ejaculated on Resident #1. She revealed that the criteria for resident-to-resident abuse was the appearance of ill outcome or resident trauma. She did not feel that Resident #1 exhibited any ill outcome or trauma. The DON revealed she had not been given the statement by CNA dated 08/11/24. The DON confirmed that the CNA still worked at the facility PRN, but she did not know if she had worked at the facility after the incident. When asked if she could find out if she had worked since the incident, the DON did not inform the investigator. When asked why the DON struck the incident report #831, she said she did not feel it was fair for that to be entered for Resident #2. The facility policy and procedures were available to her, but she did not review it before the investigation. The DON revealed she did not review the residents' medical records to determine the resident's physical and cognitive status at the time of the incident and since the incident, she did not observe the alleged victim including his interactions with staff and other residents, she did not interview the resident's representative, and she did not interview the resident's attending physician as needed to determine the resident's condition because she did not feel there was abuse. She did not interview staff members on all shifts who have had contact with the resident during the period of the alleged incident. She did not interview family members, and visitors, she did not review all events leading up to the alleged incident; and document the investigation completely and thoroughly, and she did not follow the guidelines to be used when conducting interviews when she did not obtain witness statements in writing, signed, and dated. She did not notify the ombudsman that an abuse investigation was being conducted. She did not record the findings of the investigation on approved documentation forms as outlined the facility policy. She did not provide completed documentation to the administrator and residents' representatives were not notified of the outcome immediately upon conclusion of the investigation. Review of statement by CNA dated 08/11/24 revealed that at about 10:00 pm when she went into Resident #1 and Resident #2s' room to do her rounds, Resident #2 was lying in bed with no clothes on and she told him let's get some underwear on you and some clothes. She revealed that at 1:45 am she returned to the room and checked on Resident #1 to check if his brief was wet, and she found clear white semen outside Resident #1's brief and she informed the LPN and Resident #2 was moved to another room. A review of a statement, undated, by the administrator reflected he arrived at Dallas/Fort Worth Airport on the morning of 08/11/24 to text pictures and a text message from the LPN charge nurse in the secured unit. She stated that during the night when they went to check on Resident #1 there was a clear substance on the outside of his brief. She said she thought that his roommate had ejaculated on him. She moved the roommate to another room. As I was about to get on another plane in [NAME], I called my DON to start an investigation at this. After I landed in [NAME], we spoke about where she was about the investigation. She stated the nurse did not know where it came from but did an extensive assessment of Resident #1 and said that nothing under his brief had been disturbed. Resident #1 does drool a lot and wipes [NAME] on his pants a lot during the day. This is care planned. The pictures that were sent to us showed food particles that could not come from ejaculate. The SC/CAN was working the 10:00 - 6:00 that night. She noted that a foul order was coming from the clear liquid on the top of the brief. In speaking with the DON there is not a foul order that comes from ejaculate. In interviewing the people who witnessed the clear liquid on top of the brief none of them said he was abused or neglected. The resident was not in distress physically or mentally. In reviewing the residents' files, Resident #2 has no prior history of masturbating or treating residents in a sexual manner. Resident #1 does have a large history of wiping drool on his clothing. After reviewing all the interviews and discussing it with my DON this is not a state reportable incident and is to be kept in a soft file. In an interview on 08/20/24 at 11:16 am with RN revealed she was told in report by the night LPN that when the CNA went into change Resident #1's brief, she found something particular in the brief and they, the LPN and the CNA, had suspicions that it was semen. The LPN told the RN she saved the brief with the substance and tried to call the Administrator and the DON. The RN revealed she was not aware that Resident #2 had any sexual behaviors, but they were aware that Resident #2 takes things from other residents. In an interview on 08/20/24 at 4:35 with CNA revealed she was doing her rounds and she walked in the room of Resident #1 and Resident #2 and Resident #1 was moving his head from side to side showing he was awake. She said she went to Resident #1's bed and asked if he was okay and saw he was lying in bed naked and wet, and she got him some clothes. She later came back to the room to check on Resident #1 and there was stuff on his brief. She revealed she stood there for a long time looking at it because she thought that it was semen. She revealed she called the LPN to the room, and she showed it to the LPN, and she said it was semen. They put the brief in a bag to show the Administrator and the DON. She said that the LPN called the Administrator and the DON, and they did not answer, and she moved Resident #2 to another room. The CNA revealed neither the Administrator nor the DON spoke with her about the incident. She said that the investigator was the first person to talk to her about it. She said she wrote a statement and gave it to the LPN. She revealed that Resident #1 stayed up all night and he had never stayed up all night before. She said the LPN never wavered from the idea that Resident #1 was abused, and she felt Resident #1 was safe when the LPN moved Resident #2 to another room. CNA revealed Resident #2 did not have a history of displaying any inappropriate sexual behaviors. In an interview on 08/21/24 at 3:37 pm with the Administrator revealed he did not think there was abuse because no one told him or the DON that they felt like Resident #1 was abused. The Administrator revealed that Resident #2 had bladder cancer and because he had cancer, the substance would have been bloody if he ejaculated. Resident #2 had no history of inappropriate sexual behavior. The pictures of the substance that were sent to him looked like food particles, or saliva, or drool and no one said the roommate was actually around him and standing over him. When asked if he felt that the text that reported that one resident had ejaculated on another resident was abuse, he said it might not be abuse. He gave the example of two residents in the secured unit who slapped each with no visible injury and they weren't afraid of each other not being abuse. He felt that because there were no reported signs of Resident #1 being stressed, he did not think it was abuse. He said he discussed with corporate personnel if he should report it to HHSC, the consensus was it did not fall under a reportable incident. Collectively the people he spoke with made the decision it was not reportable to the state. Review of facility policy dated 08/2022 revealed all reports of resident abuse (including injuries of unknown origin) neglect, exploitation or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting allegations of the administrator and authorities - If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are need for the protection of residents. The administrator initiates investigations. Any evidence that may be need for a criminal investigation is sealed, labeled, and protected from tampering or destruction. The administrator is responsible for keeping the resident and his/her representative (sponsor) information of the progress for the investigation. Facility policy dated 08/2022 reflected investigations may be assigned to an individual trained in reviewing, investigation, and reporting such allegation. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. Any evidence that may be needed for a criminal investigation is sealed, labeled, and protected from tampering or destruction. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. The individual conducting the investigation as a minimum will: 1. Reviews the documentation and evidence; 2. Reviews the resident's medical records to determine the resident's physical and cognitive status at the time of the incident and since the incident; 3. Observes the alleged victim including his or her interactions with staff and other residents; 4. Interviews the person(s) reporting the incident; 5. Interviews any witnesses to the incident; 6. Interviews the resident (as medically appropriate) or the resident's representative; 7. Interviews the resident's attending physician as needed to determine the resident's condition; 8. Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; 9. Interviews the resident's roommate, family members, and visitors; 10. Reviews all events leading up to the alleged incident; and documents the investigation completely and thoroughly. The following guidelines are used when conducting interviews 1. Each interview is conducted separately and in a private location 2. The [purpose and confidentiality of the interview is explained thoroughly to each person involved in the interview process 3. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement. 4. The investigator notifies the ombudsman that an abuse investigation is being conducted. The ombudsman is notified of the results of the investigation as well as any corrective measure taken; 5. The investigator consults daily with the administrator concerning the progress/finding of the investigation; 6. Upon conclusion of the investigation, the investigator records the finding of the investigation on approved documentation forms and provided the completed documentation to the administrator; 7. Within 5 business day of the incident, the administrator will provide a follow-up investigation report; 8. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified; 9. The follow up investigation report will provide as much information as possible at the time of submission of the report; 10. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made for 1 of 10 residents screened for abuse (Resident #1). The facility failed to immediately report to the State Agency (within 2 hours) an allegation sent by an LPN via text message to the administrator that she believed that Resident #2 ejaculated on Resident #1. This deficient practice delayed the investigation for the allegation and could have placed residents at risk for abuse and could have resulted in undetected abuse and/or decline in feelings of safety and well-being or psychosocial harm. Findings included: Review of Resident #1's face sheet dated 08/21/24 reflected a [AGE] year-old male, in the facility secured unit, who was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included epileptic seizures, disorder of psychological development, cognitive communication deficit, and severe intellectual disabilities. Review of Resident #1's quarterly MDS assessment, dated 06/15/24, reflected a BIMS was not conducted because the resident was rarely/never understood, indicating a severe cognitive impairment. his cognitive skills for daily decision making were severely impaired, and he never/rarely made decisions. Section GG - functional abilities and goals was not completed with the exception of impairment on both sides both upper and lower extremities. Review of Resident #1's quarterly care plan reflected the following: A focus, revised on 11/01/19, that reflected Resident #1 had been identified as PASRR positive related to an intellectual disability and related condition of epileptic seizures. A focus revised on 08/09/23 reflected Resident #1 forgot things and had no sense of safety awareness or dignity issues with an intervention dated 10/15/22 to help Resident #1 maintain dignity. A focus revised on 08/09/23 reflected Resident #1 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #1 had little or no activity involvement due to his cognitive deficits. A focus revised on 11/05/18 of activities of daily living performance deficit related to impaired mobility and cognition. A focus revised on 11/30/23 reflected Resident #1 was non-verbal and yelled off and on throughout the day. He yelled, clapped, and swayed his head back and forth as he wandered through hallways. Resident #1 had a history of sitting in laps of other residents and staff and he frequently chewed on his hands. Due to these behaviors, he was at risk for experiencing aggressive behaviors from his peers on the unit. A focus revised on 11/05/19 reflected Resident #1 had a communication problem related to intellectual disabilities, Aphasia (a condition in which the eye lacks a lens) with an intervention dated 11/05/18 to observe/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. A focus revised on 10/18/23 reflected Resident #1 received anti-anxiety medications for anxiety. A focus revised on 11/05/19 reflected Resident #1 received antidepressant medication for behaviors and insomnia. A focus revised on 01/09/24 reflected Resident #1 had a psychosocial well-being problem potential related to impaired cognition, severe and diagnosed intellectual and developmental disabilities. A focus revised on 06/27/22 reflected Resident #1 had impaired visual function related to impaired vision. Admitting hospital paperwork stated he was legally blind. A focus initiated on 08/20/24, the date the state entered the facility to investigate the complaint, revealed Resident #1 had a behavior problem r/t wipe drool and mucus on his clothing with an intervention dated 08/20/24 to clean resident hands/face and clothing as needed. Review of Resident #2's face sheet dated 08/20/24 reflected a [AGE] year-old male, in the facility secured unit, who was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included abnormal radiologic findings on diagnostic imaging of renal other diagnosis pelvis, ureter, or bladder chronic obstructive pulmonary disease with (acute) exacerbation and mild cognitive impairment of uncertain or unknown etiology. Review of Resident #2's quarterly MDS assessment, dated 05/24/24, reflected a BIMS score of 9 indicating Resident #2 was cognitively moderately impaired. Section E - Behavior potential indicators of psychosis reflected delusions (misconceptions or beliefs that are firmly held, contrary to reality). Behavioral symptom - presence & frequency behavior of this type occurred 1 to 3 days revealed other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Functional limitation in range of motion reflected no limitations in upper extremity (shoulder, elbow, wrist, hand) or lower impairment (lower extremity hip, knee, ankle, foot) and mobility devices wheelchair. Review of Resident #2's quarterly care plan reflected the following: A focus, revised on 03/08/24, that reflected Resident #2 had a potential for impaired cognition related to neurological symptoms of metabolic encephalopathy (a neurological disorder that occurs when a chemical imbalance in the blood affects the brain) with intervention dated 03/08/24 to monitor/document /report to medical doctor any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status and 03/08/2024 review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. A review of the care plan did not reveal a focus or interventions regarding Resident #2 bleeding when he urinates or bleeding at any other time. On 08/19/24 an anonymous complaint was made through TULIP, the Texas Unified Licensure Information Portal, an online system for submitting long-term care licensure applications and health care regulation Architectural Review requests, under the care areas of administration/personnel and resident/patient/client abuse. The complaint reflected, the complainant stated on 08/15/2024, or 08/16/2024, resident first name unknown (Resident #2) pulled out his penis and ejaculated on (Resident #2). The incident occurred on the facility's secured unit. Reportedly, the incident was reported by the facility's staff; however, administrator erased the report from the facility's system. The complainant would like for the facility to be investigated due to the allegations reported in this intake. Review of text message, undated, from the LPN to the administrator reflected, so I believe Resident #2 has a ejaculated on Resident #1 I am sending pictures his brief was dry inside his penis has no fluids at all bottom not penetrated sorry trying to be thorough Resident #1 has not been sleeping well for a while especially tonight. So I moved Resident #1 back with [another resident] call me back please. In an interview on 08/20/24 at 12:15 pm with the LPN revealed she was very upset about the whole incident because she thought there was abuse and the incident should have been investigated. She revealed it happened on 08/11/24 at around 10:00pm. She revealed the CNA was doing rounds and the CNA asked her to look at something. The CNA brought her Resident #1's adult brief. The brief had a fluid substance on it. The CNA asked the LPN what she thought it was and the LPN said both the CNA and the LPN thought the substance on the brief looked like semen. The LPN took photos asked the CNA to put it in a bag to show the DON. The LPN revealed the SC/CNA came by and they asked her what she thought the substance was and the LPN said the SC/CNA also thought it was semen. The LPN said she texted her administrator and called both the administrator and the DON and sent them photos of the substance on the brief. The brief was left in a bag for the DON to see. The LPN revealed she moved Resident #2 into a room with another roommate because she was concerned about Resident #1 being abused because of the substance found on the brief. She revealed Resident #1 was a good sleeper, but he did not sleep well that evening. She revealed the Administrator, who was the abuse and neglect coordinator, did not ever talk to her about the incident. She said the DON called her back at 6:00 am the following morning and said the substance could be spit and the substance was on the outside of the brief. The LPN said that the DON said she did not think it was semen and they could not prove that it was semen and they needed to let it go. The DON told the LPN to throw the brief out. The LPN revealed she felt the situation should have been investigated. When the LPN was asked if she told the DON that she did not feel there was any abuse she said she had always felt that Resident #1 was abused and that is why she moved Resident #2 out of the room, to keep Resident #1 safe. The LPN revealed that Resident #2 had previously not displayed any sexual behaviors and Resident #1, to her knowledge, had never masturbated. The LPN revealed that the DON, struck out her incident report. The LPN revealed that when the DON struck out her incident report, she because upset because they were not going to investigate the incident. In an interview on 08/21/24 at 11:05 with SC/CNA she revealed she was not working on the secured unit on 08/11/24. She was called over (unknown who called her over) and she was asked to look at a brief. She revealed she could not specify what was the substance on the brief, but said it had a strong order and it was a clear substance, it looked more like saliva. She said the LPN and the CNA expressed concerns about interaction between Resident #2 and Resident #1 because it seemed farfetched. She had worked on the secured unit consistently and Resident #2 urinated a lot and there was blood in his urine and anything that comes out of Resident #2 had blood on it. She described the substance on the brief as clear with a strong foul order. It was not milky white, and it was bubbly and looked like it had food particles in it. She did not feel like there was abuse because Resident #1 did not seem stressed. She revealed she had worked with Resident #1 for almost three years, and he drooled a lot, and he did smear it. Where it was smeared depended on where his hand landed. She did not give a written signed statement about her observation. The DON and Administrator spoke to her about it. Staff rounds every two hours, and no resident was being looked at continuously. The overnight staffing consists of one nurse and one CNA. The abuse coordinator was responsible for the investigation of any reported abuse and neglect. In an interview on 08/20/24 at 1:08 pm with the administrator revealed he was flying back from Vancouver, and he was half asleep and when he landed, he said the pictures of the substance on the brief and the text from the LPN stating she believed Resident #2 ejaculated on Resident #1 came over his phone. The Administrator revealed that Resident #1 slobbered and wiped his nose a lot. He revealed he gave the investigation to the DON because she was the clinical lead. He said the DON revealed to him that from a clinical standpoint she did not see any issue with the substance on the brief and because none of the staff witnessed the alleged incident happen and because the DON did not feel like the LPN was making an allegation of abuse and/or neglect, they did not report the incident. In an interview on 08/21/24 at 3:01 with the DON she revealed she received training on how to do abuse and neglect investigation and in this training, she was taught facilities had to report any suspicion of abuse and neglect and she was aware of the facility policies and procedures. The facility policy and procedure were available to her, but she did not review it before the investigation. She said the LNP never said to her she felt like Resident #1 had been abused, there was no proof that Resident #2 had been on Resident #1's side of the room, no one observed him standing over Resident #1 or observed Resident #2 touching Resident #1. She revealed that Resident #2 has bladder cancer and bleed a lot when he urinated. She revealed that housekeeping had called it to her attention because Resident #2's bathroom looks like a murder scene. Because there was no blood visible in the substance on the brief, she did not feel Resident #2 ejaculated on Resident #1. She revealed that the criteria for resident-to-resident abuse is the appearance of ill outcome or resident trauma. She did not feel that Resident #1 exhibited any ill outcome or trauma. Review of photograph, provided to investigator by the LPN, of an incident report #831 for Resident #2 that was stricken dated 08/11/24 revealed; strike out was dated 08/12/24 strike out reason - data entry error strike out done by DON Description: Resident's roommate was in bed and was checked and changed and an unknown substance/secretion was observed on the outside of his brief. The inside of the brief was dry, and no secretions noted in brief. Resident was the only other male in the room and was observed by this LPN sitting in a chair near roommate. Roommate #1 is nonverbal. Resident unable to give description. Immediate action taken - Resident #2 was moved to another room pending outcome of incident. Administrator called and DON also notified. Injury type - no injuries observed at time of incident. Review of statement by CNA dated 08/11/24 revealed that at about 10:00 pm when she went into Resident #1 and Resident #2s' room to do her rounds, Resident #2 was lying in bed with no clothes on and she told him let's get some underwear on you and some clothes. She revealed that at 1:45 am she returned to the room and checked on Resident #1 to check if his brief was wet, and she found clear white semen outside Resident #1's brief and she informed the LPN and Resident #2 was moved to another room. In an interview on 08/20/24 at 11:16 am with RN revealed she was told in report by the night LPN that when the CNA went into change Resident #1's brief, she found something particular in the brief and they, the LPN and the CAN, had suspicions that it was [NAME]. The LPN told the RN she saved the brief with the substance and tried to call the Administrator and the DON. The RN revealed she was not aware that Resident #2 had any sexual behaviors, but they are aware that Resident #2 takes things from other residents. In an interview on 08/20/24 at 4:35 with CNA revealed she was doing her rounds and she walked in the room of Resident #1 and Resident #2 and Resident #1 was moving his head from side to side showing he was awake. She said she went to Resident #1's bed and asked if he was okay and saw he was lying in bed naked and wet, and she got him some clothes. She later came back to the room to check on Resident #1 and there was stuff on his brief. She revealed she stood there for a long time looking at it because she thought that it was semen. She revealed she called the LPN to the room, and she showed it to the LPN, and she said it was semen. They put the brief in a bag to show the Administrator and the DON. She said that the LPN called the Administrator and the DON, and they did not answer, and she moved Resident #2 to another room. The CNA revealed neither the Administrator nor the DON spoke with her about the incident. She said that the investigator was the first person to talk to her about it. She said she wrote a statement and gave it to the LPN. She revealed that Resident #1 stayed up all night and he had never stayed up all night before. She said the LPN never wavered from the idea that Resident #1 was abused, and she felt Resident #1 was safe when the LPN moved Resident #2 to another room. CNA revealed Resident #2 did not have a history of displaying any inappropriate sexual behaviors. In an interview on 08/21/24 at 3:37 pm with the administrator revealed he did not think there was abuse because no one told him or the DON that they felt like Resident #1 was abused. The Administrator revealed that Resident #2 had bladder cancer and because he had cancer, the substance would have been bloody if he ejaculated. Resident #2 had no history of inappropriate sexual behavior. The pictures of the substance that were sent to him looked like food particles, or saliva, or drool and no one said the roommate was actually around him and standing over him. When asked if he felt that the text that reported that one resident had ejaculated on another resident was abuse, he said it might not be abuse. He gave the example of two residents in the secured unit who slapped each with no visible injury and they aren't afraid of each other not being abuse. He felt that because there were no reported signs of Resident #1 being stressed, he did not think it was abuse. He said he discussed with corporate personnel if he should report it to HHSC, the consensus was it did not fall under a reportable incident. Collectively the people he spoke with made the decision it was not reportable to the state. Review of facility policy dated 08/2022 revealed all reports of resident abuse (including injuries of unknown origin) neglect, exploitation or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting allegations of the administrator and authorities - If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are need for the protection of residents. The administrator initiates investigations. Any evidence that may be need for a criminal investigation is sealed, labeled, and protected from tampering or destruction. The administrator is responsible for keeping the resident and his/her representative (sponsor) information of the progress for the investigation.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure [NAME] A, Dishwasher C, and DA B wore hairnets and beard restraints when cooking, preparing, or assembling food. This failure could place residents who received meals and/or snacks from the kitchen at risk of foodborne illness due to physical contamination. Findings included: An observation of the dining room on 06/29/24 at 9:58 a.m. revealed [NAME] A walked out of the kitchen and into the dining room. [NAME] A was not wearing a beard restraint. Dishwasher C was also not wearing a hairnet when washing dishes at the dishwashing station in the kitchen. During an interview on 06/29/24 at 10:02 a.m., [NAME] A revealed he was not wearing a beard restraint, but he wore a hair net. [NAME] A stated food service staff were required to wear hairnets once they entered the kitchen. [NAME] A explained only food service staff on the service line and cooks must wear hairnets. [NAME] A stated he was not required to wear a beard restraint. [NAME] A also stated he was trained by the DM on when to wear hairnets. [NAME] A also stated not wearing hairnets and beard restraints could cause residents to find hair in food. During an interview on 06/29/24 at 10:09 a.m., Dishwasher C revealed all food service staff in the kitchen were required to wear hairnets. Dishwasher C stated dishwashers were required to wear hairnets. Dishwasher C also stated she did not wear a hairnet because she was late to work, forgot to grab one, and started working on dishes. Dishwasher C stated residents' health could not be affected by dishwashers not wearing hairnets. Dishwasher C stated when entering the kitchen, staff must wear a hairnet. Dishwasher C stated she received training and was in-serviced on hairnets every three and a half weeks by the DM. An observation of the kitchen on 06/29/24 at 10:16 a.m. revealed DA B was not wearing a hairnet and assembling food at the food service line. During an interview on 06/29/24 at 10:16 a.m., DA B revealed all food service staff in the kitchen were required to wear hairnets when they step into the kitchen. DA B stated there was no reason why she was not wearing a hairnet. DA B also stated not wearing hairnets could cause residents to find hair in their food. DA B stated she was trained and in-serviced monthly by the DM on when to wear hairnets. During an interview on 06/29/24 at 12:31 p.m., the ADM revealed food service staff were required to wear hairnets and beard restraints in the food preparation area. During an interview on 06/29/24 at 12:42 p.m., the DM revealed she trained and in-serviced staff on 06/10/24 on hairnets and beard restraints. The DM explained she taught staff about duties, responsibilities, and the handbook, which included hairnet policy and other general information. The DM stated the food service staff were required to wear hairnets, especially in the food preparation area. The DM explained Dishwashers were not required to wear hairnets, but she still required them to wear hairnets. The DM stated residents' health could not be affected if food service staff did not wear hairnets and beard restraints in the food preparation area. Record review of the facility's Food and Nutrition Services in-services, dated 06/17/24, revealed the DM in-serviced staff on duties and general information for the kitchen. [NAME] A, DA B, and Dishwasher C signed, which indicated they acknowledged the duties and general information for the kitchen the DM reviewed with them. Record review of the facility's food preparation and service policy, revised November 2022, revealed staff required to do the following: 8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.

Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 6 of 6 administrative staff responsible for monitoring and implementing the facility policy and procedures for 1 of 1 facility reviewed for Administration. 1. The Medical Director, NP, DON, and ADON failed to monitor routine laboratory results for residents on an anticonvulsant medication for seizure management. 2. The DON and ADON failed to ensure nursing staff had the appropriate competencies related to an LVAD (life-saving device). 3. The Medical Director, NP, Administrator, DON, ADON, and Infection Control Preventionist failed to implement and monitor the infection control program policies and procedures to include C&S results that revealed resistant organisms, contagious infections, and the appropriate use of PPE. 4. The Medical Director, NP, DON, ADON, and Infection Control Preventionist failed to provide oversight and education for the nursing staff on infection control policies and procedures. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:58 PM. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for serious injury, serious harm, serious impairment, or death. The findings included: 1. Record review of the face sheet, dated [DATE], revealed Resident #61 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of epileptic seizures related to external causes (chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Record review of the quarterly MDS assessment, dated [DATE], revealed Resident #61 had no speech and was rarely or never understood by staff. The MDS revealed Resident #61 was rarely or never able to understand others. The MDS revealed Resident #61 had poor short-term and long-term memory and had no memory recall ability. The MDS revealed Resident #61 rarely or never made decisions. The MDS revealed Resident #61 had continuous inattention behaviors. The MDS revealed Resident #61 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised on [DATE], revealed Resident #61 had a seizure disorder. The interventions included: give seizure medication as order by the physician and labs per orders. Record review of the order summary report, dated [DATE], revealed Resident #61 had an order for the following: o Keppra, Tegretol, Depakote laboratory levels every 30 days for seizures, which started on [DATE]. o Depakote sprinkles (anticonvulsant) 125 mg - give one capsule orally one time a day, which started on [DATE]. o Valproic acid (anticonvulsant) solution 250 mg/mL - give 5 mL by mouth three times a day, which started on [DATE]. o carbamazepine suspension 100 mg/ 5 mL - give 10 mL three times a day for anticonvulsant, which started on [DATE]. o Keppra 500 mg/ 5 mL - give 5 mL two times a day related to seizures, which started on [DATE]. Record review of the nursing progress notes, dated [DATE], revealed Resident #61 had seizure activity, in which he was sent to the ER. Record review of the nursing progress notes, dated [DATE], revealed Resident #61 had seizure activity, in which the NP at the facility assessed the resident and ordered stat labs. Record review of the lab results, collected on [DATE], revealed Resident #61 had a low valproic acid (Depakote) level at 46 ug/mL (micrograms per milliliter). The reference range for valproic acid was 50 - 100 ug/mL. There were missing labs for [DATE], [DATE], and [DATE]. Record review of the MAR, dated [DATE], revealed Resident #61 had no documentation of medication administration for Depakote sprinkles on [DATE], [DATE], and [DATE]. The MAR further revealed Resident #61 had no documentation of medication administration for valproic acid on [DATE] and [DATE]. Record review of the MAR, dated [DATE], revealed Resident #61 had no documentation of medication administration for Depakote sprinkles on [DATE], [DATE], and [DATE]. The MAR further revealed Resident #61 had no documentation of medication administration for valproic acid on [DATE]. Record review of the MAR, dated [DATE], revealed Resident #61 had no documentation of medication administration for valproic acid on [DATE], the day before Resident #61 experienced seizure activity. 2. Record review of the face sheet, dated [DATE], revealed Resident #43 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures (seizures which affect initially only one hemisphere of the brain). Record review of the comprehensive MDS assessment, dated [DATE], revealed Resident #43 had clear speech and was understood by staff. The MDS revealed Resident #43 was able to understand others. The MDS revealed Resident #43 had a BIMS of 10, which indicated moderately impaired cognition. The MDS revealed Resident #43 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised [DATE], revealed Resident #43 had a risk for injury related to seizure disorder. The interventions included: give seizure medication as ordered by the doctor and monitor lab per MD orders, resident refused lab draw. Record review of the order summary report, dated [DATE], revealed Resident #43 had an order for the following: o Routine topiramate and Keppra laboratory levels for seizures, which started on [DATE]. No frequency was listed. o Keppra (anticonvulsant) 1,250 mg two times a day related to seizures, which started on [DATE]. o Topiramate 100 mg two times a day for seizures, which started on [DATE]. Record review of the nursing progress note, dated [DATE], revealed Resident #43 had seizure activity, which caused a fall. Record review of the nursing progress note, dated [DATE], revealed Resident #43 had seizure activity. Record review of the nursing progress note, dated [DATE], revealed Resident #43 had seizure activity, which caused a fall. Record review of the lab results from the neurologist, dated [DATE], revealed Resident #43 had critically high levels of Keppra. The neurologist adjusted the dosage of her medications. There were no lab results drawn for [DATE], [DATE], or [DATE]. 3. Record review of the face sheet, dated [DATE], revealed Resident #12 was a [AGE] year-old female who initially admitted on [DATE] with diagnoses of history of cerebral infarction (stroke), multiple sclerosis (immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions), and neurologic disorders in Lyme disease (tick-borne disease caused by bacteria that results in rashes, fever, and fatigue). Record review of the quarterly MDS assessment, dated [DATE], revealed Resident #12 had clear speech and was understood by staff. The MDS revealed Resident #12 was able to understand others. The MDS revealed Resident #12 had a BIMS of 14, which indicated no cognitive impairment. The MDS revealed Resident #12 had an active diagnosis of seizure disorder. Record review of the comprehensive care plan, revised on [DATE], revealed Resident #12 had no care plan in place for her seizure disorder. Record review of the order summary report dated [DATE] revealed Resident #12 had the following orders: o Primidone and Phenobarbital laboratory concentration every 6 months. o Primidone 50 mg three times a day for an anticonvulsant, which started on [DATE]. Record review of the nursing progress notes, dated [DATE] to [DATE], revealed Resident #12 had no seizure activity. Record review of the lab results tab in the electronic medical record, accessed [DATE], revealed Resident #12 had no primidone or phenobarbital level drawn in 2023. 4. Record review of the face sheet, dated [DATE], revealed Resident #65 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified convulsions (medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking). Record review of the quarterly MDS assessment, dated [DATE], revealed Resident #65 had clear speech and was understood by staff. The MDS revealed Resident #65 was able to understand others. The MDS revealed Resident #65 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed Resident #65 had an active diagnosis of seizure disorder. Record review of the comprehensive care plan, revised on [DATE], revealed Resident #65 had no care plan in place for her seizure disorder. Record review of the order summary report, dated [DATE], revealed Resident #65 had the following orders: o Depakote laboratory level every three months, which started on [DATE]. o Phenytoin laboratory level every 6 months, which started on [DATE]. o Dilantin (anticonvulsant) 300mg one time a day for seizures, which started on [DATE]. o Depakote 250 mg twice daily, which started on [DATE]. Record review of the nursing progress notes, dated [DATE] to [DATE] revealed no seizure activity. Record review of the lab results tab in the electronic medical record, accessed [DATE], revealed Resident #65 had no Depakote level drawn in [DATE], [DATE], [DATE], or [DATE]. The result tab revealed Resident #65 had no phenytoin level draw in [DATE]. Record review of the lab results, dated [DATE], revealed Resident #65 had a phenytoin level of 3.6 ug/ML, which was subtherapeutic (low). Resident #65 had a valproic acid (Depakote) level of 33 ug/mL, which was subtherapeutic. 5. Record review of the face sheet, dated [DATE], revealed Resident #17 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of unspecified convulsions (medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking). Record review of the quarterly MDS assessment, dated [DATE], revealed Resident #17 had clear speech and was understood by staff. The MDS revealed Resident #17 was able to understand other. The MDS revealed Resident #17 had a BIMS of 7, which indicated severe cognitive impairment. The MDS revealed Resident #17 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised [DATE], revealed Resident #17 had a seizure disorder and was at risk for injury. The interventions included: give seizure medications as ordered by the physician and obtain and observe lab work as ordered. Record review of the order summary report, dated [DATE], revealed Resident #17 had an order for the following: o Phenytoin laboratory level every 3 months, which started on [DATE]. o Dilantin (phenytoin) 400 mg at bedtime for an anticonvulsant, which started on [DATE]. Record review of the progress notes, dated [DATE] to [DATE], revealed Resident #17 had no seizure activity. Record review of the last lab results, dated [DATE], revealed Resident #17 had a phenytoin level of 5.4, which was subtherapeutic (low). There were no further labs drawn for 2023. During an interview on [DATE] beginning at 8:06 AM, the DON stated there was no system in place for monitoring routine labs. The DON stated the NP and Medical Director no longer ordered routine labs since the NP was in the facility daily. The DON was unaware Resident's #61, #43, #12, #65, and #17 had routine labs levels ordered for their seizure medications. The DON stated it was important to ensure lab levels were obtained as ordered by the physician to ensure seizure medication levels were therapeutic and to prevent seizures. The DON stated if the labs were refused, it should have been documented in the nursing progress notes and included on the care plan. During an interview on [DATE] beginning at 9:02 AM, LVN P stated she had only been hired at the facility for approximately 2 months. LVN P stated Resident #61 had a history of seizures but was unsure when his last seizure happened. LVN P was unsure when the last routine levels were obtained for Resident #61. LVN P stated she was unaware Resident #61 had routine lab orders to monitor levels for his seizure medications. LVN P stated the charge nurse was responsible for administering medications in the secured unit. LVN P stated she was not used to the electronic monitoring system and forgot to sign out Resident #6's Depakote sprinkles and valproic acid medication for seizures. LVN P stated she gave the medications. LVN P stated it was important to document the medication administration for seizure medications because if it is not documented, it is not completed. LVN P stated if the seizure medications were not administered Resident #61 could have had a seizure. LVN P stated she was unsure if Resident #61 had routine labs drawn. LVN P stated labs were followed up on when the results came back but there was no system for tracking the labs that needed to have been drawn. During an interview on [DATE] beginning at 9:15 AM, the NP stated the frequency of obtaining lab levels for seizure medications was determined by the resident's clinical status. The NP stated if a resident was having seizures frequently, she expected labs to have been drawn every 30 days. The NP stated if a resident's seizures were stable, she expected lab levels to have been drawn every 3 - 6 months. The NP stated she expected lab levels on seizure medications to have been drawn per orders. The NP stated she was unaware Resident's #61, #43, #12, #65, and #17 were not receiving routine lab services to monitor levels on their seizure medications. The NP stated she reviewed labs daily that were received from the laboratory, but there was no system in place to ensure routine labs were being performed. The NP stated she was unaware Resident #61 was missing doses of his seizure medications. The NP stated missing doses of seizure medications could have led to seizures. The NP stated consistently subtherapeutic levels of seizure medications could have led to seizures. During an interview on [DATE] beginning at 10:33 AM, the Laboratory Tech stated there were no standing orders for routine lab levels for seizure medication in their system for Resident #61 and Resident #43. The Laboratory Tech refused to give the surveyor any more information and transferred the call to the Medical Records department. The Medical Record department did not answer, and brief message was left with a number to return the call. No call was received upon exit of the facility. During an interview on [DATE] beginning at 12:53 PM, the DON stated the dashboard on the electronic charting system would show missing documentation on the MARs. The DON stated if there was missing documentation on the MAR, she would have reached out to the nurse to return to the facility to complete the documentation. The DON was unsure why the documentation was missing for Resident #61 in October, November, and December. The DON stated she expected the nursing staff to sign out all medication and treatments as they were given. The DON stated, if it was not documented it was not completed. The DON stated missing doses of seizure medications could have caused adverse reaction and led to seizures. During an interview on [DATE] beginning at 6:14 PM, the Medical Director stated drawing lab levels for seizure medications did not matter. The Medical Director stated medications were adjusted based on the resident's clinical status, not the seizure medication levels. The Medical Director stated it was standard practice to order lab levels on seizure medications every 3 - 6 months, and not every 30 days. The Medial Director stated he received the orders from the facility and signed off on them but just missed the lab orders for Resident #61 and Resident #43. The Medical Director stated he was unaware the routine lab for seizure medications were not being obtained. The Medical Director stated he expected labs to have been obtained per the orders. The Medical Director stated he just reviewed his notes to ensure labs were being completed. The Medical Director stated he would have to look at his notes more closely and pay attention to the orders, to ensure labs were obtained routinely. The Medical Director stated there was no risk for seizures in residents who had a subtherapeutic level. The Medical Director stated he was more concerned with the adverse effects seizure medications could have caused the residents, such as kidney failure and decreased liver function. 6. Record review of Resident #231's face sheet, dated [DATE], indicated Resident #231 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that was present over a long time. Record review of the physician order summary report dated [DATE] indicated to monitor Resident #231 LVAD frequently; ensure monitor was plugged in and battery packs time six charging and if electricity goes out, immediately plug into green extension cord under bed and into red emergency outlet every shift and monitor LVAD frequently, ensure monitor was plugged with a start date [DATE]. Record review of the MDS assessment indicated Resident #231 was admitted to the facility less than 21 days ago. No MDS for Resident #231 was completed prior to exit. Record review of Resident #231's admission/baseline care plan dated [DATE] indicated Resident #231 had an LVAD. The care plan did not address any goals or interventions related to the LVAD. Record review of the blood pressure summary indicated Resident #231's blood pressures were: o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg o [DATE]; ,d+[DATE] mmHg Record review of the TAR dated [DATE]-[DATE] indicated Resident #231 was receiving: *Cozaar 100 mg; 1 tablet via Peg-tube in the morning for hypertension. Hold if BP <,d+[DATE] or Pulse <60 with a start date [DATE]. * Norvasc 10 mg; 1 tablet via Peg-Tube in the morning for hypertension. Hold if BP <,d+[DATE] with a start date [DATE]. *Metoprolol Tartrate 50 mg; 1 tablet via Peg-Tube two times a day for hypertension with a start date [DATE]. *Hydralazine 25 mg; 3 tablets via Peg-Tube three times a day for hypertension. Hold if BP <,d+[DATE] or Pulse <60 with a start date [DATE]. Record review of the TAR indicated the 6:00 p.m. Hydralazine 25 mg dose was not given on [DATE]. An attempted interview on [DATE] at 10:54 a.m. with Resident #231, indicated she was non-interview able. During an interview on [DATE] at 10:55 a.m., Resident #231's family member stated she was concerned the facility was not able to provide the care that was needed for her family member. When asked if she could provide the surveyor more information, Resident #231 family member stated over the weekend she watched nurses check Resident #231 blood pressure using an automatic blood pressure cuff. Resident #231 family member stated a manual blood pressure and doppler should be used. Resident #231 family member stated she was told by the nursing staff that they were not able to get a blood pressure reading. Resident #231 family member stated the facility did not have a doppler to obtain Resident #231 radial (wrist) pulse. Resident #231 family member stated Resident #231 did not have a regular blood pressure just a MAP which was one number. Resident #231 family member stated she instructed several nursing staff on how to correctly check Resident #231 MAP. Resident #231 family stated she was told by the facility they had all the equipment needed for Resident #231's LVAD. Resident #231 family stated not knowing how to handle Resident #231 LVAD correctly could possibly cause death. During an interview on [DATE] at 12:08 p.m., RN D stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. RN D stated she attempted several times on [DATE], [DATE], and [DATE] to check Resident #231 blood pressure with an automatic blood pressure cuff. RN D stated she was told by Resident #231 family member that she must use a manual blood pressure cuff and a doppler to obtain a reading. RN D stated when she checked her blood pressure, she would only get one number. RN D stated before she realized that she would only get one number, she would document in Resident #231's chart a number that she made up because at that time, she did not know she was supposed to only get one number. RN D stated the blood pressure readings in the chart were not accurate. RN D stated even though the numbers she charted were outside the norm of the parameters she never contacted the doctor or inform anyone. RN D stated false documentation was not appropriate but there was no other way to document in the chart. RN D stated she administered Resident #231's blood medications even though she did not have an accurate reading. RN D stated she had not dealt with a LVAD in years that she felt familiar enough to provide care to without been educated on first. RN D stated it was important to know the risk and side effects to prevent possible death. During an interview on [DATE] at 12:42 p.m., LVN E stated he had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN E stated he was trained by the family member on [DATE] on how to use the doppler to get Resident #231's MAP. LVN E stated the DON provided him a pamphlet with a contact number for the representative of the LVAD clinic. LVN E stated it was important to be educated and trained on the LVAD because the LVAD kept Resident #231 alive. LVN E stated the LVAD was a life saving intervention. During an interview on [DATE] at 12:57 p.m., the DON stated she had taken care of LVAD residents before in a home setting. The DON stated she felt competent along with instructions that she received from the family that was caring for her that the facility could provide adequate care. The DON stated Resident #231 family member came in on [DATE] and showed what to do in an emergency situation. The DON stated from her knowledge she thought one could auscultate a mean arterial pressure (measures the flow, resistance, and pressure in the arteries during one heartbeat) with a manual blood pressure cuff and stethoscope. The DON stated she should have notified the LVAD clinic to have them come in and do the training prior to Resident #231 admission. The DON stated the blood pressure medications should not have had parameters because Resident #231 would not have a two number blood pressure just a MAP. The DON stated she did not instruct her staff until surveyor intervention on how to document in the chart the MAP. The DON stated up until [DATE] the nurses were either guessing Resident #231 MAP or did not get one at all. The DON stated she was instructed by the family to give the blood pressure medication no matter what. The DON stated she relied on the family because they had cared for her since 2017. The DON stated she thought that Resident #231 MAP should be between ,d+[DATE]. The DON stated she delegated the ADON to in-service LVN G and LVN GGG. The DON stated LVN G and LVN GGG were responsible for in servicing the other nursing staff that provided care for Resident #231. The DON stated from her knowledge there was a discussion about Resident #231 with the MD. The DON stated it was sometimes during the week of [DATE] when the facility received the referral from the hospital. The DON stated she reviewed the referral and saw that she had a LVAD and thought her and her staff were competent enough to provide care to her. The DON stated after discussing with the MD it was in agreeable that Resident #231 was appropriate for the facility. The DON stated it was important for the nursing staff to be trained, educated, and know how to document appropriate to prevent possible death. During a telephone interview on [DATE] at 1:31 p.m., LVN KK stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN KK stated she used an electronic blood pressure cuff but did not get a reading. LVN KK stated she never notified the DON or MD regarding Resident #231 blood pressure. LVN KK stated she should have notified someone. LVN KK stated it was important to be trained and educated on the LVAD device because it could have been life threatening. During an interview on [DATE] at 1:38 p.m., LVN G stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN G stated she was in service on [DATE] by LVN E. LVN G stated she did not know how to take Resident #231 blood pressure this weekend. LVN G stated she used an automatic cuff on her arm. LVN G stated she did not get a reading. LVN G stated she contacted the nurse practitioner and was told that she would not get a reading such as a top and bottom number. LVN G stated there was no additional training provided. LVN G stated she was told by the nurse practitioner that Resident #231 would need her medications and there were no parameters to monitor for. LVN G stated she administered Resident #231's blood pressure medications. LVN G stated Resident #231 had a life saving device and not knowing that how to correctly check her MAP could have cause her to have a stroke or died . LVN G stated she should have asked the DON and nurse practitioner further questions about the LVAD device. During an interview on [DATE] at 1:44 p.m., the Nurse Practitioner stated a LVAD helps the heart pump when it did not do it on its own. The Nurse Practitioner stated she was aware that Resident #231 was coming to the facility, but she was unaware of the MAP parameters. The Nurse Practitioner stated when she reconciled the medications, she did not see anything with parameters. The Nurse Practitioner stated she thought because of the cardiomyopathy she needed the medications. The Nurse Practitioner stated the nursing staff should have contacted the doctor to get parameters for the MAP. The Nurse Practitioner stated the staff should have been in serviced on the LVAD. The Nurse Practitioner stated she instructed LVN G to give Resident #231 her blood pressure medication but do not put blood pressure parameters on the medications because with a MAP you only get one number. The Nurse Practitioner stated Resident #231 MAP could only be obtained by a manual blood pressure using a doppler to check the radial pulse. The Nurse Practitioner stated not knowing how to take care of a resident with a LVAD put them at risk for dying. During an interview on [DATE] at 2:54 p.m., the LVAD consultant stated a LVAD was a lifesaving device that helped the left side of the heart push blood forward to help with perfusion (passage of bodily fluids) to Resident #231's body. The LVAD consultant stated the nurse must use a manual blood pressure and a doppler to get Resident #231 MAP. The LVAD Consultant stated not using a manual blood pressure and doppler, the nurse would not get an accurate blood pressure. The LVAD Consultant stated Resident #231 MAP parameters were between ,d+[DATE]. The LVAD Consultant stated the facility contacted the clinic on [DATE] requesting someone to come out and in service their staff. The LVAD Consultant stated it was important to know about the LVAD device because it put the resident at risk for possible death. During an interview on [DATE] at 5:00 p.m., the Medical Director stated he was aware that Resident #231 was in the facility. The Medical Director stated he remembered hearing from someone after she was admitted but prior to that it was not ran by him. The Medical Director stated if he had of known prior to Resident #231 admission, he would have had to find out how stable she was and made sure the staff were aware of how to care for someone with an LVAD device. The Medical Director stated he was told that there had not been any education provided so he will be coming in that day to provide education to the nurses. The Medical Director stated the facility should have contacted him to get the MAP parameters. The Medical Director stated he considered the LVAD a life sustaining device and not knowing how to care for the device could cause the resident to die. During an interview on [DATE] at 5:26 p.m., LVN CCC stated she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN CCC stated she tried to check Resident #231's blood pressure using an automatic wrist cuff and it did not read. LVN CCC stated she had to do it with an automatic upper arm cuff and Resident #231 blood pressure reading was low, so she held the blood pressure medication. LVN CCC stated the only instructions she received was what to do if the electricity went out. LVN CCC stated she had never cared for anyone with an LVAD device. LVN CCC stated she did not notify the Medical Director that Resident #231's blood pressure was low. LVN CCC stated she just used the parameters on the medications to determine if the medication should be held. LVN CCC stated she should have contacted the doctor to let him know about her blood pressure. LVN CCC stated she was focused on not giving the medication because if the blood pressure was low and she gave the medication she could have possibly died . LVN CCC stated it was important to know about the LVAD device because it could have been life threatening. During a telephone interview on [DATE] at 6:10 p.m., LVN NNN stated she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN NNN stated she was not required to check Resident #231's blood pressure on her shift due to the time that she resumed care of Resident #231. LVN NNN stated if she had to check her blood pressure, she would have used an automatic cuff like she did on everyone else. LVN NNN stated the nurse she received report from instructed her on what to do in an emergency situation. LVN NNN stated she knew the LVAD device was a life saving device but was not familiar with it. LVN NNN stated she did not know the risk associated with monitoring a resident with a LVAD. During an interview on [DATE] at 6:25 p.m., the ADON stated she in-serviced LVN G on [DATE] what to do in an emergency situation when handling Resident #231. The ADON stated she informed LVN G to in-service the oncoming nurse about how to handle the LVAD in an emergency situation. The ADON stated herself and the DON went in on [DATE] and spoke with Resident #231's family member. The ADON stated they were instructed on what to do in an emergency situation and how to handle the device. The ADON stated they were informed that a manual cuff and doppler must be used to get her MAP. The ADON stated the family member gave them the parameters, but the ADON was unable to recall the numbers. The ADON stated the family member informed them that she would bring the doppler from home to the facility on [DATE]. The ADON stated the facility should have had their own doppler prior to Resident #231 arrival to the facility. The ADON stated she was nervous with the LVAD device coming into the facility. The ADON stated the doctor should have been informed about the parameters and just the overall care of the device. The ADON stated the risk associated with[TRUNCATED]

Based on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 8 of 8 nurses (LVN G, E, KK, CCC, GGG, NNN, OOO, and RN D ) reviewed for nursing services. 1. The facility did not ensure nursing staff was trained and educated on the LVAD (a device that is used in the treatment of end-stage heart failure). 2. The facility did not ensure nursing staff was trained on complications to monitor for Resident #231's LVAD. 3. The facility did not ensure nursing staff obtained MAP (average calculated blood pressure in an individual during a single cardiac cycle) pressures and documented them appropriately on the MAR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:07 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential more than minimal harm that is not Immediate Jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings included: Record review of Resident #231's face sheet, dated [DATE], indicated Resident #231 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that was present over a long time. Record review of the physician order summary report dated [DATE] indicated to monitor Resident #231 LVAD frequently; ensure monitor was plugged in and battery packs time six charging and if electricity goes out, immediately plug into green extension cord under bed and into red emergency outlet every shift and monitor LVAD frequently, ensure monitor was plugged with a start date [DATE]. Record review of the MDS assessment indicated Resident #231 was admitted to the facility less than 21 days ago. No MDS for Resident #231 was completed prior to exit. Record review of Resident #231's admission/baseline care plan dated [DATE] indicated Resident #231 had an LVAD. The care plan did not address any goals or interventions related to the LVAD. Record review of the blood pressure summary indicated Resident #231's blood pressures were: [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg [DATE]; ,d+[DATE] mmHg Record review of the TAR dated [DATE]-[DATE] indicated Resident #231 was receiving: *Cozaar 100 mg; 1 tablet via Peg-tube in the morning for hypertension. Hold if BP <,d+[DATE] or Pulse <60 with a start date [DATE]. * Norvasc 10 mg; 1 tablet via Peg-Tube in the morning for hypertension. Hold if BP <,d+[DATE] with a start date [DATE]. *Metoprolol Tartrate 50 mg; 1 tablet via Peg-Tube two times a day for hypertension with a start date [DATE]. *Hydralazine 25 mg; 3 tablets via Peg-Tube three times a day for hypertension. Hold if BP <,d+[DATE] or Pulse <60 with a start date [DATE]. Record review of the TAR indicated the 6:00 p.m. Hydralazine 25 mg dose was not given on [DATE]. An attempted interview on [DATE] at 10:54 a.m. with Resident #231, indicated she was non-interview able. During an interview on [DATE] at 10:55 a.m., Resident #231's family member stated she was concerned the facility was not able to provide the care that was needed for her family member. When asked if she could provide the surveyor more information, Resident #231 family member stated over the weekend she watched nurses check Resident #231 blood pressure using an automatic blood pressure cuff. Resident #231 family member stated a manual blood pressure and doppler should be used. Resident #231 family member stated she was told by the nursing staff that they were not able to get a blood pressure reading. Resident #231 family member stated the facility did not have a doppler to obtain Resident #231 radial (wrist) pulse. Resident #231 family member stated Resident #231 did not have a regular blood pressure just a MAP which was one number. Resident #231 family member stated she instructed several nursing staff on how to correctly check Resident #231 MAP. Resident #231 family stated she was told by the facility they had all the equipment needed for Resident #231's LVAD. Resident #231 family stated not knowing how to handle Resident #231 LVAD correctly could possibly cause death. During an interview on [DATE] at 12:08 p.m., RN D stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. RN D stated she attempted several times on [DATE], [DATE], and [DATE] to check Resident #231 blood pressure with an automatic blood pressure cuff. RN D stated she was told by Resident #231 family member that she must use a manual blood pressure cuff and a doppler to obtain a reading. RN D stated when she checked her blood pressure, she would only get one number. RN D stated before she realized that she would only get one number, she would document in Resident #231's chart a number that she made up because at that time, she did not know she was supposed to only get one number. RN D stated the blood pressure readings in the chart were not accurate. RN D stated even though the numbers she charted were outside the norm of the parameters she never contacted the doctor or inform anyone. RN D stated false documentation was not appropriate but there was no other way to document in the chart. RN D stated she administered Resident #231's blood medications even though she did not have an accurate reading. RN D stated she had not dealt with a LVAD in years that she felt familiar enough to provide care to without been educated on first. RN D stated it was important to know the risk and side effects to prevent possible death. During an interview on [DATE] at 12:42 p.m., LVN E stated he had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN E stated he was trained by the family member on [DATE] on how to use the doppler to get Resident #231's MAP. LVN E stated the DON provided him a pamphlet with a contact number for the representative of the LVAD clinic. LVN E stated it was important to be educated and trained on the LVAD because the LVAD kept Resident #231 alive. LVN E stated the LVAD was a life saving intervention. During an interview on [DATE] at 12:57 p.m., the DON stated she had taken care of LVAD residents before in a home setting. The DON stated she felt competent along with instructions that she received from the family that was caring for her that the facility could provide adequate care. The DON stated Resident #231 family member came in on [DATE] and showed what to do in an emergency situation. The DON stated from her knowledge she thought one could auscultate a MAP with a manual blood pressure cuff and stethoscope. The DON stated she should have notified the LVAD clinic to have them come in and do the training prior to Resident #231 admission. The DON stated the blood pressure medications should not have had parameters because Resident #231 would not have a two number blood pressure just a MAP. The DON stated she did not instruct her staff until surveyor intervention on how to document in the chart the MAP. The DON stated up until [DATE] the nurses were either guessing Resident #231 MAP or did not get one at all. The DON stated she was instructed by the family to give the blood pressure medication no matter what. The DON stated she relied on the family because they had cared for her since 2017. The DON stated she thought that Resident #231 MAP should be between ,d+[DATE]. The DON stated she delegated the ADON to in-service LVN G and LVN GGG. The DON stated LVN G and LVN GGG were responsible for in servicing the other nursing staff that provided care for Resident #231. The DON stated from her knowledge there was a discussion about Resident #231 with the MD. The DON stated it was sometimes during the week of [DATE] when the facility received the referral from the hospital. The DON stated she reviewed the referral and saw that she had a LVAD and thought her and her staff were competent enough to provide care to her. The DON stated after discussing with the MD it was in agreeable that Resident #231 was appropriate for the facility. The DON stated it was important for the nursing staff to be trained, educated, and know how to document appropriate to prevent possible death. During a telephone interview on [DATE] at 1:31 p.m., LVN KK stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN KK stated she used an electronic blood pressure cuff but did not get a reading. LVN KK stated she never notified the DON or MD regarding Resident #231 blood pressure. LVN KK stated she should have notified someone. LVN KK stated it was important to be trained and educated on the LVAD device because it could have been life threatening. During an interview on [DATE] at 1:38 p.m., LVN G stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN G stated she was in service on [DATE] by LVN E. LVN G stated she did not know how to take Resident #231 blood pressure this weekend. LVN G stated she used an automatic cuff on her arm. LVN G stated she did not get a reading. LVN G stated she contacted the nurse practitioner and was told that she would not get a reading such as a top and bottom number. LVN G stated there was no additional training provided. LVN G stated she was told by the nurse practitioner that Resident #231 would need her medications and there were no parameters to monitor for. LVN G stated she administered Resident #231's blood pressure medications. LVN G stated Resident #231 had a life saving device and not knowing that how to correctly check her MAP could have cause her to have a stroke or died . LVN G stated she should have asked the DON and nurse practitioner further questions about the LVAD device. During an interview on [DATE] at 1:44 p.m., the Nurse Practitioner stated a LVAD helps the heart pump when it did not do it on its own. The Nurse Practitioner stated she was aware that Resident #231 was coming to the facility, but she was unaware of the MAP parameters. The Nurse Practitioner stated when she reconciled the medications, she did not see anything with parameters. The Nurse Practitioner stated she thought because of the cardiomyopathy she needed the medications. The Nurse Practitioner stated the nursing staff should have contacted the doctor to get parameters for the MAP. The Nurse Practitioner stated the staff should have been in serviced on the LVAD. The Nurse Practitioner stated she instructed LVN G to give Resident #231 her blood pressure medication but do not put blood pressure parameters on the medications because with a MAP you only get one number. The Nurse Practitioner stated Resident #231 MAP could only be obtained by a manual blood pressure using a doppler to check the radial pulse. The Nurse Practitioner stated not knowing how to take care of a resident with a LVAD put them at risk for dying. During an interview on [DATE] at 2:54 p.m., the LVAD consultant stated a LVAD was a lifesaving device that helped the left side of the heart push blood forward to help with perfusion (passage of bodily fluids) to Resident #231's body. The LVAD consultant stated the nurse must use a manual blood pressure and a doppler to get Resident #231 MAP. The LVAD Consultant stated not using a manual blood pressure and doppler, the nurse would not get an accurate blood pressure. The LVAD Consultant stated Resident #231 MAP parameters were between ,d+[DATE]. The LVAD Consultant stated the facility contacted the clinic on [DATE] requesting someone to come out and in service their staff. The LVAD Consultant stated it was important to know about the LVAD device because it put the resident at risk for possible death. During an interview on [DATE] at 5:00 p.m., the Medical Director stated he was aware that Resident #231 was in the facility. The Medical Director stated he remembered hearing from someone after she was admitted but prior to that it was not ran by him. The Medical Director stated if he had of known prior to Resident #231 admission, he would have had to find out how stable she was and made sure the staff were aware of how to care for someone with an LVAD device. The Medical Director stated he was told that there had not been any education provided so he will be coming in that day to provide education to the nurses. The Medical Director stated the facility should have contacted him to get the MAP parameters. The Medical Director stated he considered the LVAD a life sustaining device and not knowing how to care for the device could cause the resident to die. During an interview on [DATE] at 5:26 p.m., LVN CCC stated she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN CCC stated she tried to check Resident #231's blood pressure using an automatic wrist cuff and it did not read. LVN CCC stated she had to do it with an automatic upper arm cuff and Resident #231 blood pressure reading was low, so she held the blood pressure medication. LVN CCC stated the only instructions she received was what to do if the electricity went out. LVN CCC stated she had never cared for anyone with an LVAD device. LVN CCC stated she did not notify the Medical Director that Resident #231's blood pressure was low. LVN CCC stated she just used the parameters on the medications to determine if the medication should be held. LVN CCC stated she should have contacted the doctor to let him know about her blood pressure. LVN CCC stated she was focused on not giving the medication because if the blood pressure was low and she gave the medication she could have possibly died . LVN CCC stated it was important to know about the LVAD device because it could have been life threatening. During a telephone interview on [DATE] at 6:10 p.m., LVN NNN stated she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN NNN stated she was not required to check Resident #231's blood pressure on her shift due to the time that she resumed care of Resident #231. LVN NNN stated if she had to check her blood pressure, she would have used an automatic cuff like she did on everyone else. LVN NNN stated the nurse she received report from instructed her on what to do in an emergency situation. LVN NNN stated she knew the LVAD device was a life saving device but was not familiar with it. LVN NNN stated she did not know the risk associated with monitoring a resident with a LVAD. During an interview on [DATE] at 6:25 p.m., the ADON stated she in-serviced LVN G on [DATE] what to do in an emergency situation when handling Resident #231. The ADON stated she informed LVN G to in-service the oncoming nurse about how to handle the LVAD in an emergency situation. The ADON stated herself and the DON went in on [DATE] and spoke with Resident #231's family member. The ADON stated they were instructed on what to do in an emergency situation and how to handle the device. The ADON stated they were informed that a manual cuff and doppler must be used to get her MAP. The ADON stated the family member gave them the parameters, but the ADON was unable to recall the numbers. The ADON stated the family member informed them that she would bring the doppler from home to the facility on [DATE]. The ADON stated the facility should have had their own doppler prior to Resident #231 arrival to the facility. The ADON stated she was nervous with the LVAD device coming into the facility. The ADON stated the doctor should have been informed about the parameters and just the overall care of the device. The ADON stated the risk associated with not properly knowing how to manage or monitor Resident #231 LVAD was death. During a telephone interview on [DATE] at 6:45 p.m., LVN OOO stated she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN OOO stated she checked Resident #231 blood pressure using an automatic cuff. LVN OOO stated after she checked her blood pressure, Resident #231 family member asked her about the doppler. LVN OOO stated the family stated to her while in the room with Resident #231 that she was informed that the facility knew how to take care of a resident with LVAD. LVN OOO stated she apologized and went to review Resident #231 electronic chart. LVN OOO stated after she reviewed the chart, she did not see anything about checking the blood pressure with a manual cuff or doppler. LVN OOO stated she even went and spoke with the other nurse that was on her hall and they did not know either. LVN OOO stated she knew nothing about MAP parameters. LVN OOO stated she used the parameters that was on the blood pressure medications. LVN OOO stated she administered the blood pressure medications even though she did not know if the medications should be held or not. LVN OOO stated not fully aware of the in and out of LVAD device could be detrimental to Resident #231. During an interview on [DATE] at 12:36 p.m., LVN GGG stated she was in serviced on how to connect and disconnect the machine during an emergency situation. LVN GGG stated other than that she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN GGG stated it was important to know how to take care of someone with a LVAD device because it could be fatal, that is the only way for blood supply to the heart. During an interview on [DATE] at 6:11 p.m., the Administrator stated he expected his staff to be competent in taking care of someone with a LVAD device. The Administrator stated the DON and the ADON was responsible for reviewing the admission referral and ensuring the staff were able to properly care for the resident. The Administrator stated the DON discussed with him about Resident #231 and she felt competent in providing care for her. The Administrator stated, when she feels comfortable, I feel comfortable. The Administrator stated the facility did not ask the Medical Director to review admissions before he and the DON accepted the resident. The Administrator stated the DON should have in serviced the nursing staff prior to assuming care for Resident #231. The Administrator stated the DON should have made sure she had all the equipment in the facility. The Administrator stated this was important for the safety of the resident and to prevent death. Record review of the facility's policy titled Staffing, Sufficient and Competent Nursing last revised ,d+[DATE], indicated, . our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . 6. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment .Competent Staff (3). Staff must demonstrate the skills and techniques necessary to care for resident's needs . The Administrator was notified on [DATE] at 5:00 PM that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on [DATE] at 5:07 PM and the plan of removal was requested. The Plan of Removal was accepted on [DATE] at 9:18 a.m. and included: LETTER OF ABATEMENT FOR REMOVAL OF IMMEDIATE JEOPARDY [DATE] On [DATE], a survey was initiated at Facility XXX. The facility was notified at 5:10 pm on [DATE], a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at Facility XXX constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F726-Competent Staff and the facility's failure to provide training and education on the LVAD has the potential to cause death to Resident #231 Immediate Corrections Implemented for Removal of Immediate Jeopardy. On [DATE]th, 2023, at 5:10pm the following actions were taken; Action: On [DATE], Resident #231 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with LVAD monitoring and care by licensed nurses. These measures include Assessment to include monitoring for continuous humming when auscultating heart sounds to validate that the device is functioning properly, observing for s/s of infection, power management, monitoring MAP with goal of ,d+[DATE]mm Hg, shortness of breath and increased MAP. Orders in place for cord and battery management and dressing changes and monitoring of MAP. On [DATE] The Director of Nursing/Designee notified resident #231's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered. The care plan was initiated to reflect LVAD and required care and monitoring. Orders in place for cord and battery management and dressing changes and monitoring of MAP. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/Designee Action: Medical director completed education with Director of nursing and nursing leadership on the purpose, function, and potential complications as well as the requirements to monitor and care for LVAD, including monitoring mean arterial pressures (MAP), battery and cord management, and cleaning and care of drive line. Start Date: [DATE] Completion Date: [DATE] Responsible: Medical Director IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: The Director of Nursing/Designee completed a sweep of all facility residents to identify any residents with LVAD to have appropriate monitoring including MAP pressures and documentation in place. There were no other residents identified as having an LVAD. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: Director of nursing completed education with licensed staff caring for resident #231 on [DATE] on requirements to monitor and care for LVAD, including monitoring blood pressure and mean arterial pressure (MAP); the goal is 60 mm Hg to 90 mm Hg. Elevated MAP decreases flow and perfusion, battery, and cord management, monitor for complications, SOB, increased pulse pressure, decrease in pump flow rate, and steady increase in the pump power over several days and symptoms of infection and to notify MD immediately if any of these problems occur, and cleaning and care of drive line to validate resident is cared for and receiving appropriate for care of LVAD. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/Designee Action: Director of Nursing arranged education with all licensed staff on [DATE] at 10:00am from LVAD clinic to educate on all cares and monitoring required for care of resident with LVAD, to document competencies for all licensed nursing staff in facility. Training will be recorded and any nursing staff who work infrequently or were not in attendance will be educated on the above prior to their next scheduled shift. This education will include monitoring blood pressure and mean arterial pressure (MAP); the goal is 60 mm Hg to 90 mm Hg. Elevated MAP decreases flow and perfusion, battery, and cord management, monitor for complications, SOB, increased pulse pressure, decrease in pump flow rate, and steady increase in the pump power over several days and symptoms of infection and to notify MD immediately if any of these problems occur, and cleaning and care of drive line. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/designee Action: The Director of Nursing/designee will conduct daily reviews of new and admission orders to validate that nursing staff have appropriate competencies associated with any medical devices ordered or in use by residents prior to providing care. The Director of Nursing/designee if needed will arrange for additional training to ensure that nurses demonstrate competency in the care of residents with devices found to be new to the facility or infrequently used. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing Ad Hoc QAPI meeting was held on [DATE] with the Medical Director, Administrator, Director of Nursing, and Nurse Management, Area Operations Director, Corporate clinical consultant, Pharmacy consultant to review Immediate Jeopardy findings and plan of removal for identified deficient practice. Please accept this letter as our plan of removal for determination of the Immediate Jeopardy issued [DATE]. Monitoring of the Plan of Removal from [DATE]-[DATE] included the following: 1) Record review of the electronic medical records indicated Resident #231 was assessed to validate the resident was not exhibiting s/sx of physical or psychosocial distress. 2) Record review of the electronic medical records indicated the DON completed a sweep of all facility residents to identify any residents with LVAD to have the appropriate monitoring. Resident #213 was the only resident in the facility with a LVAD. 3) During an interview on [DATE] at 12:15 p.m. with the DON indicated she could explain the purpose, function, and potential complications as well as the requirements to monitor and care for LVAD. 4) During an interview on [DATE] beginning at 9:30 a.m., with the DON, LVN G, LVN GGG, LVN CCC, LVN UUU, Infection Preventionist and the Nurse Practitioner indicated they could explain the requirements to monitor and care for LVAD, monitor for complications, and symptoms of infection and to notify MD immediately if any of these problems occur, and cleaning and care of drive line to validate resident is cared for and receiving appropriate for care of LVAD. 5) During an interview on [DATE] beginning at 9:30 a.m. with the DON, ADON, LVN E, LVN GGG, MDS Coordinator X, MDS Coordinator L, RN D, LVN G, LVN Z indicated they could explain the education they received from the LVAD consultant on all cares and monitoring required for care of resident with LVAD, to document competencies for all licensed nursing staff in facility, symptoms of infection and to notify MD immediately if any of these problems occur. 7) Record review of the daily reviews of new and admission orders dated [DATE] indicated there was no new admissions with medical devices. 8) Record review of the LVAD Training in-service, dated [DATE], indicated the DON was provided education on the purpose, function, and potential complications as well as the requirements to monitor and care for LVAD. 9) Record review of the LVAD Training in-service, dated [DATE], indicated the DON, LVN G, LVN GGG, LVN CCC, LVN UUU, Infection Preventionist and the Nurse Practitioner were provided education on the requirements to monitor and care for LVAD, which included the procedure for obtaining the MAP using a manual blood pressure cuff and the doppler, monitor for complications, and symptoms of infection and to notify MD immediately if any of these problems occur, and cleaning and care of drive line to validate resident is cared for and receiving appropriate for care of LVAD. 10) Record review of the LVAD Education in-service, dated [DATE], indicated the DON, ADON, LVN E, LVN GGG, MDS Coordinator X, MDS Coordinator L, RN D, LVN G, LVN Z were provided education from the LVAD consultant on all cares and monitoring required for care of resident with LVAD, to document competencies for all licensed nursing staff in facility which included the procedure for obtaining the MAP using a manual blood pressure cuff and the doppler, symptoms of infection and to notify MD immediately if any of these problems occur. 11) Record review of the QAPI Plan of correction sign in sheet for [DATE]. On [DATE] at 1:35 p.m., the Administrator was informed the IJ was removed: however, the facility remained out of compliance at no actual harm with potential more than minimal harm that is not Immediate Jeopardy with a scope identified as pattern 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 laboratory services were obtained to meet the needs of 5 of 12 residents (Resident's #12, #17, #43, #61, and #65) reviewed for laboratory services. 1. The facility did not ensure Resident #61 had his routine Keppra, Tegretol, and Depakote levels monitored as ordered by the physician. 2. The facility did not ensure Resident #43 had her routine topiramate and Keppra levels monitored as ordered by the physician. 3. The facility did not ensure Resident #12 had her routine primidone and phenobarbital levels monitored as ordered by the physician. 4. The facility did not ensure Resident #65 had her routine Depakote and phenytoin (Dilantin) levels monitored as ordered by the physician. 5. The facility did not ensure Resident #17 had his routine phenytoin (Dilantin) levels monitored as ordered by the physician. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/12/23 at 2:40 PM. While the IJ was removed on 12/13/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as pattern 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 subtherapeutic or toxic levels of seizure medications. The finding included: 1. Record review of the face sheet, dated 12/11/23, revealed Resident #61 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of epileptic seizures related to external causes (chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Record review of the quarterly MDS assessment, dated 11/15/23, revealed Resident #61 had no speech and was rarely or never understood by staff. The MDS revealed Resident #61 was rarely or never able to understand others. The MDS revealed Resident #61 had poor short-term and long-term memory and had no memory recall ability. The MDS revealed Resident #61 rarely or never made decisions. The MDS revealed Resident #61 had continuous inattention behaviors. The MDS revealed Resident #61 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised on 11/06/23, revealed Resident #61 had a seizure disorder. The interventions included: give seizure medication as order by the physician and labs per orders. Record review of the order summary report, dated 12/12/23, revealed Resident #61 had an order for the following: Keppra, Tegretol, Depakote laboratory levels every 30 days for seizures, which started on 02/17/21. Depakote sprinkles (anticonvulsant) 125 mg - give one capsule orally one time a day, which started on 07/21/22. Valproic acid (anticonvulsant) solution 250 mg/mL - give 5 mL by mouth three times a day, which started on 07/15/21. carbamazepine suspension 100 mg/ 5 mL - give 10 mL three times a day for anticonvulsant, which started on 06/14/23. Keppra 500 mg/ 5 mL - give 5 mL two times a day related to seizures, which started on 10/23/2018. Record review of the nursing progress notes, dated 09/08/23, revealed Resident #61 had seizure activity, in which he was sent to the ER. Record review of the nursing progress notes, dated 12/06/23, revealed Resident #61 had seizure activity, in which the NP at the facility assessed the resident and ordered stat labs. Record review of the lab results, collected on 12/06/23, revealed Resident #61 had a low valproic acid (Depakote) level at 46 ug/mL (micrograms per milliliter). The reference range for valproic acid was 50 - 100 ug/mL. There were missing labs for September 2023, October 2023, and November 2023. Record review of the MAR, dated October 2023, revealed Resident #61 had no documentation of medication administration for Depakote sprinkles on 10/05/23, 10/10/23, and 10/28/23. The MAR further revealed Resident #61 had no documentation of medication administration for valproic acid on 10/05/23 and 10/28/23. Record review of the MAR, dated November 2023, revealed Resident #61 had no documentation of medication administration for Depakote sprinkles on 11/11/23, 11/12/23, and 11/20/23. The MAR further revealed Resident #61 had no documentation of medication administration for valproic acid on 11/29/23. Record review of the MAR, dated December 2023, revealed Resident #61 had no documentation of medication administration for valproic acid on 12/05/23, the day before Resident #61 experienced seizure activity. 2. Record review of the face sheet, dated 12/12/23, revealed Resident #43 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures (seizures which affect initially only one hemisphere of the brain). Record review of the comprehensive MDS assessment, dated 10/03/23, revealed Resident #43 had clear speech and was understood by staff. The MDS revealed Resident #43 was able to understand others. The MDS revealed Resident #43 had a BIMS of 10, which indicated moderately impaired cognition. The MDS revealed Resident #43 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised 11/16/23, revealed Resident #43 had a risk for injury related to seizure disorder. The interventions included: give seizure medication as ordered by the doctor and monitor lab per MD orders, resident refused lab draw. Record review of the order summary report, dated 12/12/23, revealed Resident #43 had an order for the following: Routine topiramate and Keppra laboratory levels for seizures, which started on 05/02/23. No frequency was listed. Keppra (anticonvulsant) 1,250 mg two times a day related to seizures, which started on 10/11/23. Topiramate 100 mg two times a day for seizures, which started on 02/04/23. Record review of the nursing progress note, dated 06/13/23, revealed Resident #43 had seizure activity, which caused a fall with no injuries. Record review of the nursing progress note, dated 07/10/23, revealed Resident #43 had seizure activity. Record review of the nursing progress note, dated 09/13/23, revealed Resident #43 had seizure activity, which caused a fall with no injuries. Record review of the lab results from the neurologist, dated 10/10/2, revealed Resident #43 had critically high levels of Keppra. The neurologist adjusted the dosage of her medications. There were no lab results drawn for July 2023, August 2023, or November 2023. 3. Record review of the face sheet, dated 12/12/23, revealed Resident #12 was a [AGE] year-old female who initially admitted on [DATE] with diagnoses of history of cerebral infarction (stroke), multiple sclerosis (immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions), and neurologic disorders in Lyme disease (tick-borne disease caused by bacteria that results in rashes, fever, and fatigue). Record review of the quarterly MDS assessment, dated 10/16/23, revealed Resident #12 had clear speech and was understood by staff. The MDS revealed Resident #12 was able to understand others. The MDS revealed Resident #12 had a BIMS of 14, which indicated no cognitive impairment. The MDS revealed Resident #12 had an active diagnosis of seizure disorder. Record review of the comprehensive care plan, revised on 12/06/23, revealed Resident #12 had no care plan in place for her seizure disorder. Record review of the order summary report dated 12/12/23 revealed Resident #12 had the following orders: Primidone and Phenobarbital laboratory concentration every 6 months. Primidone 50 mg three times a day for an anticonvulsant, which started on 06/19/19. Record review of the nursing progress notes, dated 01/01/23 to 12/12/23, revealed Resident #12 had no seizure activity. Record review of the lab results tab in the electronic medical record, accessed 12/12/23, revealed Resident #12 had no primidone or phenobarbital level drawn in 2023. 4. Record review of the face sheet, dated 12/12/23, revealed Resident #65 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified convulsions (medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking). Record review of the quarterly MDS assessment, dated 11/21/23, revealed Resident #65 had clear speech and was understood by staff. The MDS revealed Resident #65 was able to understand others. The MDS revealed Resident #65 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed Resident #65 had an active diagnosis of seizure disorder. Record review of the comprehensive care plan, revised on 11/06/23, revealed Resident #65 had no care plan in place for her seizure disorder. Record review of the order summary report, dated 12/16/23, revealed Resident #65 had the following orders: Depakote laboratory level every three months, which started on 12/10/20. Phenytoin laboratory level every 6 months, which started on 04/24/20. Dilantin (anticonvulsant) 300mg one time a day for seizures, which started on 02/04/20. Depakote 250 mg twice daily, which started on 02/12/22. Record review of the nursing progress notes, dated 09/11/23 to 10/12/23 revealed no seizure activity. Record review of the lab results tab in the electronic medical record, accessed 12/12/23, revealed Resident #65 had no Depakote level drawn in March 2023, April 2023, August 2023, or September 2023. The result tab revealed Resident #65 had no phenytoin level draw in November 2023. Record review of the lab results, dated 12/13/23, revealed Resident #65 had a phenytoin level of 3.6 ug/ML, which was subtherapeutic (low). Resident #65 had a valproic acid (Depakote) level of 33 ug/mL, which was subtherapeutic. 5. Record review of the face sheet, dated 12/12/23, revealed Resident #17 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of unspecified convulsions (medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking). Record review of the quarterly MDS assessment, dated 11/02/23, revealed Resident #17 had clear speech and was understood by staff. The MDS revealed Resident #17 was able to understand other. The MDS revealed Resident #17 had a BIMS of 7, which indicated severe cognitive impairment. The MDS revealed Resident #17 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised 11/06/23, revealed Resident #17 had a seizure disorder and was at risk for injury. The interventions included: give seizure medications as ordered by the physician and obtain and observe lab work as ordered. Record review of the order summary report, dated 12/12/23, revealed Resident #17 had an order for the following: Phenytoin laboratory level every 3 months, which started on 04/30/18. Dilantin (phenytoin) 400 mg at bedtime for an anticonvulsant, which started on 09/19/17. Record review of the progress notes, dated 03/09/23 to 05/10/23, revealed Resident #17 had no seizure activity. Record review of the last lab results, dated 03/16/23, revealed Resident #17 had a phenytoin level of 5.4, which was subtherapeutic (low). There were no further labs drawn for 2023. During an interview on 12/12/23 beginning at 8:06 AM, the DON stated there was no system in place for monitoring routine labs. The DON stated the NP and Medical Director no longer ordered routine labs since the NP was in the facility daily. The DON was unaware Resident's #61, #43, #12, #65, and #17 had routine labs levels ordered for their seizure medications. The DON stated it was important to ensure lab levels were obtained as ordered by the physician to ensure seizure medication levels were therapeutic and to prevent seizures. The DON stated if the labs were refused, it should have been documented in the nursing progress notes and included on the care plan. During an interview on 12/12/23 beginning at 9:02 AM, LVN P stated she had only been hired at the facility for approximately 2 months ago. LVN P stated Resident #61 had a history of seizures but was unsure when his last seizure happened. LVN P was unsure when the last routine levels were obtained for Resident #61. LVN P stated she was unaware Resident #61 had routine lab orders to monitor levels for his seizure medications. LVN P stated the charge nurse was responsible for administering medications in the secured unit. LVN P stated she was not used to the electronic monitoring system and forgot to sign out Resident #6's Depakote sprinkles and valproic acid medication for seizures. LVN P stated she gave the medications. LVN P stated it was important to document the medication administration for seizure medications because if it is not documented, it is not completed. LVN P stated if the seizure medications were not administered Resident #61 could have had a seizure. LVN P stated she was unsure if Resident #61 had routine labs drawn. LVN P stated labs were followed up on when the results came back but there was no system for tracking the labs that needed to have been drawn. During an interview on 12/12/23 beginning at 9:15 AM, the NP stated the frequency of obtaining lab levels for seizure medications was determined by the resident's clinical status. The NP stated if a resident was having seizures frequently, she expected labs to have been drawn every 30 days. The NP stated if a resident's seizures were stable, she expected lab levels to have been drawn every 3 - 6 months. The NP stated she expected lab levels on seizure medications to have been drawn per orders. The NP stated she was unaware Resident's #61, #43, #12, #65, and #17 were not receiving routine lab services to monitor levels on their seizure medications. The NP stated she reviewed labs daily that were received from the laboratory, but there was no system in place to ensure routine labs were being performed. The NP stated she was unaware Resident #61 was missing doses of his seizure medications. The NP stated missing doses of seizure medications could have led to seizures. The NP stated consistently subtherapeutic levels of seizure medications could have led to seizures. During an interview on 12/12/23 beginning at 10:33 AM, the Laboratory Tech stated there were no standing orders for routine lab levels for seizure medication in their system for Resident #61 and Resident #43. The Laboratory Tech refused to give the surveyor any more information and transferred the call to the Medical Records department. The Medical Record department did not answer, and brief message was left with a number to return the call. No call was received upon exit of the facility. During an interview on 12/12/23 beginning at 12:53 PM, the DON stated the dashboard on the electronic charting system would show missing documentation on the MARs. The DON stated if there was missing documentation on the MAR, she would have reached out to the nurse to return to the facility to complete the documentation. The DON was unsure why the documentation was missing for Resident #61 in October, November, and December. The DON stated she expected the nursing staff to sign out all medication and treatments as they were given. The DON stated, if it was not documented it was not completed. The DON stated missing doses of seizure medications could have caused adverse reaction and led to seizures. Record review of the Lab and Diagnostic Test Results - Clinical Protocol policy, revised November 2018, revealed physician will identify, and order diagnostic and lab testing based on resident's diagnostic and monitoring needs .staff will process and arrange for tests .laboratory provider will report test results to facility .a nurse will try to determine whether the test was done .to monitor a drug level . The policy did not address monitoring to ensure routine labs were completed. The Administrator was notified on 12/12/23 at 2:40 PM that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on 12/12/23 at 2:45 PM and the plan of removal was requested. During an interview on 12/12/23 beginning at 6:14 PM, the Medical Director stated drawing lab levels for seizure medications did not matter. The Medical Director stated medications were adjusted based on the resident's clinical status, not the seizure medication levels. The Medical Director stated it was standard practice to order lab levels on seizure medications every 3 - 6 months, and not every 30 days. The Medial Director stated he received the orders from the facility and signed off on them but just missed the lab orders for Resident #61 and Resident #43. The Medical Director stated he was unaware the routine lab for seizure medications were not being obtained. The Medical Director stated he expected labs to have been obtained per the orders. The Medical Director stated he just reviewed his notes to ensure labs were being completed. The Medical Director stated he would have to look at his notes more closely and pay attention to the orders, to ensure labs were obtained routinely. The Medical Director stated there was no risk for seizures in residents who had a subtherapeutic level. The Medical Director stated he was more concerned with the adverse effects seizure medications could have caused the residents, such as kidney failure and decreased liver function. The facility's plan of removal was accepted on 12/13/23 at 3:08 PM and included the following: Immediate Corrections Implemented for Removal of Immediate Jeopardy. On December 12th, 2023, at 2:40 pm the following actions were taken. Action: On 12/12/2023, Resident #61 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified resident #61's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered. All previous routine lab orders were discontinued. Resident had Keppra and Valproic acid labs on 12/6/23 and a Valproic lab on 12/8/23. New lab order for Valproic Acid order was received on 12/13/23 to be drawn on 3/8/24. The care plan was reviewed, and no changes were needed. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee Action: On 12/12/2023, Resident #43 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified the resident #43's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered, and the care plan was updated accordingly. All previous routine lab orders were discontinued. New orders for Valproic Acid, Keppra, and Topamax levels were obtained 12/12/23. Care plan was review and no changes were needed. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee Action: On 12/12/2023, Resident #12 was assessed by the Director of Nursing to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified the resident #12's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered, and the care plan was updated accordingly. New order for Primidone level was obtained on 12/12/23. Care plan was added for seizure disorder on 12-13-23. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee Action: On 12/12/2023, Resident #65 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified the resident #65's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered, and the care plan was updated accordingly. New Order obtained 12-12-23 for Valproic Acid level. Care plan was added for seizure disorder 12-13-23. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee Action: On 12/12/2023, Resident #17 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified the resident #17's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered. All previous routine lab orders were discontinued. A Dilantin level order was obtained on 12/12/23. Care plan was reviewed and no changes were needed. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: The Director of Nursing/Designee completed a sweep of all facility residents' medication to identify any residents receiving seizure medication that require routine laboratory monitoring, to validate labs have been drawn and monitored as indicated and ordered by physician and that evidence of appropriate follow-through on any levels that fell outside of therapeutic range existed. Any missed orders, draws or follow-through on abnormal levels were addressed immediately. All residents who require lab monitoring for other medications (antipsychotics, antibiotics, anticoagulants) were reviewed an labs were completed and will be follow up on as results are received. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: Corporate Clinical Consultant completed education with Director of nursing and nursing leadership on requirements to monitor laboratory processes per physician orders, to validate labs are drawn per orders and received and follow up orders initiated as indicated by MD. DON and/or designee will review that labs have been drawn and results received timely for 7 days to ensure labs are being completed. Labs drawn and results will be reviewed daily Monday through Friday thereafter. DON and/or designee will pull the lab order listing report to track labs to ensure they are being completed and followed up on. This has been added as a tab to our in-house tracking spreadsheet tool. NP or physician will review labs Monday through Friday and give further orders as needed. Physician will be notified immediately for any critical results. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Corporate Clinical Consultant Action: Corporate clinical consultant completed education with consultant pharmacist to include in monthly medical regimen review, monitoring required for medication with laboratory levels to be drawn. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Corporate Clinical Consultant Action: Labs will be reviewed daily by the DON/Designee and followed up accordingly for one week, and then daily Monday through Friday thereafter. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Corporate Clinical Consultant Action: The Director of Nursing/Designee provided education to nursing staff regarding the requirement that residents receive labs as ordered by the physician for seizure management and that there is appropriate follow-through on any levels found to be out of range. Nurses were educated on the new process for tracking and ensuring labs are drawn. This education included residents with routine lab orders, new orders, and results. Physician will be notified immediately for any critical results. Any nursing staff who work infrequently or were not in attendance will be educated on the above prior to their next scheduled shift. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing Ad Hoc QAPI meeting was held on 12/12/23 with the Medical Director, Administrator, Director of Nursing, and Nurse Management, Area Operations Director, Corporate clinical consultant, Pharmacy consultant to review Immediate Jeopardy findings and plan of removal for identified deficient practice. On 12/13/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. Record review of the nursing progress note, dated 12/12/23, revealed Resident #61 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. The responsible party was notified. 2. Record review of the nursing progress note, dated 12/13/23, revealed Resident #43 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. The responsible party was notified. 3. Record review of the nursing progress note, dated 12/13/23, revealed Resident #12 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. 4. Record review of the nursing progress note, dated 12/12/23, revealed Resident #65 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. The responsible party was notified. 5. Record review of the nursing progress note, dated 12/12/23, revealed Resident #17 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. The responsible party was notified. 6. Record review of Resident's #12 and #65 comprehensive care plan, initiated on 12/13/23, revealed the care plan was added to address the seizure disorder. 7. Record review of Resident's #61, #43, #12, #65, and #17 order summary report, accessed on 12/13/23, revealed laboratory orders were updated per the physician orders. 8. Record review of a list of residents receiving medications that required level monitoring revealed the nursing staff completed a sweep to identify potential residents at risk. 9. Record review of the Patient Service Log revealed a list of 36 resident's, who received medications that required levels, in which labs were ordered and drawn by the physician. The list included Resident's #43, #12, #65, and #17. Resident #61 had recent labs and no new labs were ordered. 10. During interviews on 12/13/23 between 4:45 PM and 7:19 PM, revealed RN D, RN AAA, RN DDD, RN EEE, MDS L, MDS X, MDS AA, LVN E, LVN G, LVN P, LVN Z, LVN CC, LVN MM, LVN CCC. LVN FFF, and LVN GGG were able to correctly identify medications that required lab levels to be drawn. They all stated they should notify the physician immediately for any labs or levels or that were abnormal. They were all able to identify the new process for tracking labs and how to follow up on labs. 11. During an interview on 12/13/23 beginning at 6:08 PM, the Corporate Clinical Consultant stated he provided education to the DON, ADON, and Infection Control Preventionist on requirements to monitor laboratory processes per physician orders daily for seven day then Monday - Friday, to validate that labs were drawn per orders by pulling a report in the electronic charting system, and to ensure labs were received and followed up on as needed by the physician and documented on an internal house tool. The Corporate Clinical Consultant stated he instructed the nurse management that the physician should review the labs daily and should have been notified immediately for abnormal results that were critical. The Corporate Clinical Consultant stated he educated the Pharmacy Consultant to include monitoring required for medications with laboratory levels to be drawn on her monthly medical regimen review. 12. During an interview on 12/13/23 beginning at 6:17 PM, the DON stated she was provided education from the Corporate Clinical Consultant regarding the process and importance of tracking the routine labs ordered by the physician. The DON stated she was to monitor daily for seven days then Monday - Friday. The DON stated she was to document the labs drawn, the follow up, and new orders that were received on an internal house tool. The DON stated she then provided education to the nursing staff on the process for obtaining labs for residents on a seizure medication and to notify the physician immediately for any critical labs. 13. During an interview on 12/13/23 beginning at 6:34 PM, the ADON stated she was provided education on new process for obtaining laboratory results on residents who took a seizure medication. The ADON stated when a new seizure medication was ordered, she was instructed to obtain laboratory orders as well. The ADON stated every morning she was to make sure an order and lab report was obtained and to verify orders and labs were followed up on. The ADON stated she was to document the new orders and follow up on an internal house tool. 14. During an interview on 12/13/23 beginning at 7:24 PM, the Pharmacy Consultant stated she was informed and provided education to include monitoring required for medications with laboratory levels to be drawn on her monthly medical regimen review. the Pharmacy Consultant stated medication pass had been observed during monthly visits to the facility. The Pharmacy Consultant stated no issues were identified during medication pass and the facility staff signed out the medication as it was given. The Pharmacy consultant stated it was important to ensure medication administration was documented on the MAR to ensure continuity of care. 15. Record review of an Ad Hoc QAPI Meeting, dated 12/12/23, revealed the Administrator, DON, Corporate Clinical Consultant, Area Director of Operations, Medical Director, and Pharmacy Consultant were in attendance and an action plan was developed. On 12/13/23 at 7:32 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

45879 46892 47006 Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 7 residents (Resident's #25, #68, #91, #107, #111, #127, #330, ) and 5 out of 15 staff (CNA O, CNA PP, CNA SSS, MA A, and RN D) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility did not implement antibiotic orders for Resident #127, who had signs and symptoms of an UTI, that had not resolved with treatment. 2. The facility failed to identify a resistant organism that was cultured from Resident #127's urine. 2a. The facility failed to ensure contact isolation precautions were ordered and implemented for Resident #127. 3. The facility failed to identify signs and symptoms of a UTI for Resident #91. 4. The facility failed to identify a resistant organism that was cultured from Resident #107's urine. 4a. The facility failed to ensure contact isolation precautions were ordered and implemented for Resident #107 until surveyor interventions. 5. The facility failed to ensure CNA PP properly cleaned the peri-area, changed gloves, and performed hand hygiene before going from dirty to clean while providing incontinent care to Resident #107 (who was positive for ESBL (resistant bacteria) and required contact isolation). 6. The facility failed to identify a resistant organism that was cultured from Resident #111's urine. 6a. The facility failed to ensure contact isolation precautions were ordered and implemented for Resident #111 until surveyor interventions. 7. The facility failed to ensure staff wore appropriate PPE in Resident #330's room, who was positive for clostridium difficile (bacteria) and required contact isolation precautions. 8. The facility failed to ensure MA A performed hand hygiene while administering medications to Resident #2, Resident #16, and Resident #40. 9. The facility failed to ensure CNA PP properly cleaned the peri-area, changed gloves, and performed hand hygiene before going from dirty to clean while providing incontinent care to Resident #25. 10. The facility did not ensure CNA SSS performed hand hygiene and changed gloves while providing incontinent care to Resident #68. 11. The facility failed to ensure facility staff were educated on when to initiate isolation precautions. An Immediate Jeopardy (IJ) was identified on 12/15/23 at 12:58 PM. While the IJ was removed on 12/16/23, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope identified as patterned 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 increased risk for serious complications, hospitalization , and death from a communicable disease that could diminish the resident's quality of life. The findings included: 1. Record review the face sheet, dated 12/15/23, revealed Resident #127 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of malignant neoplasm of right breast (breast cancer) and UTI (infection of the urinary system, usually caused from bacteria). Record review of the discharge MDS assessment, dated 11/05/23, revealed Resident #127 had an unplanned discharge to the acute hospital. The MDS revealed Resident #127 had an indwelling catheter. The MDS revealed Resident #127 had an active diagnosis of UTI during the last 30 days. Record review of the comprehensive care plan, initiated on 10/18/23, revealed Resident #127 had no care plan that addressed UTI status or risk. Record review of the order summary report, dated 12/15/23, revealed Resident #127 had an antibiotic order for Cipro, which started on 11/05/23. Record review of the nursing progress notes, dated 10/18/23, revealed Resident #127 was complaining of dysuria (painful urination). Ordered UA with C&S. Changed foley bag and flushed. No return. Foley catheter changed using sterile technique, 16FR 10cc bulb. Dark yellow urine returned. Resident #127 tolerated well. Collected UA, as ordered by hospice. Hospice nurse, here and gave order from Dr. to start Bactrim DS one po BID x7 days for UTI. Hospice will deliver today. Resident states she already feels better after foley changed. Call light and water in reach. Record review of the nursing progress notes, dated 11/04/23 at 9:34 PM, revealed Resident #127 had zero output for shift. Tried to flush catheter without success. Replaced catheter. (16fr) Hospice nurse arrived per request of family. Hospice was updated on change of status that resident just recently had. Also advised of issues with catheter. New order for UA with C&S. This was obtained and lab notified. Hospice stated that they will likely bring antibiotics in the morning. Record review of Resident #127's nursing progress notes, dated 11/05/23 at 5:37 AM, revealed Throughout the night, the resident had change in mental status. Resident #127 was moaning off & on. She would hold a cup or pitcher of water to her mouth but not drink and would just spill. Resident's eye remained wide open for the most part of the night. She had to be prompted on taking medicine and swallowing. Record review of Resident #127's nursing progress notes, dated 11/05/23 at 9:31 PM, revealed Resident #127 was found in bed by the medication aide unable to respond to commands given. I was called because medication aide stated the resident did not look right. Patients skin was cool to the touch. Patient did not respond when given orders and just stared off into the distance. The nurses note further revealed Resident was sent to the ER. Record review of the nursing progress notes, dated between 10/17/23 and 11/05/23, revealed no further follow up was documented for Resident #127's UTI. Record review of the MAR, dated October 2023, revealed Resident #127 was started on Bactrim DS (antibiotic) on 10/18/23 for diagnosis of UTI. The MAR revealed Resident #127 completed the Bactrim DS on 10/25/23. Record review of the MAR, dated November 2023, revealed Resident #127 was not administered her antibiotic medication, Cipro that was ordered for an UTI related to a change of condition. Record review of the lab results, collected 10/18/23, revealed Resident #127 had a moderate number of bacteria in her urine. The C&S results revealed Klebsiella pneumoniae (bacteria) was present in her urine. Record review of the lab results, collected 11/04/23, revealed Resident #127 had many bacteria in her urine. The C&S results revealed the culture was considered mixed and would not be processed any further. Record review of the Infection Surveillance Form, effective 10/20/23, revealed Resident #127 was not started on isolation precautions. Record review of the hospital records, dated 12/15/23, revealed Resident #127 was suspected to have septic shock likely from a urinary source. During an interview on 12/15/23 beginning at 9:27 AM, Resident #127's family member stated she was the one that caught Resident #127's UTI. Resident #127's family member stated she informed the nurse on 11/04/23 of Resident #127's dark blue or purple colored urine and changes. The family member stated the nurses would not have done anything for Resident #127 if she had not intervened. The family member said the physician had ordered antibiotics but Resident #127 was unable to start the antibiotic because they had to wait for it to have been delivered. The family member stated Resident #127 was sent to the hospital the next evening on 11/05/23 and she was not notified of the transfer. The family member stated the hospital called her at 2 or 3 AM on the morning of 11/06/23. The family member stated when she arrived at the hospital, she was informed by the physician that her mother was dying from sepsis and had only a few hours until her last moments. The family member stated Resident #127 passed away on 11/06/23 at 8:40 PM. The family member stated she felt like Resident #127's death was unnecessary and preventable. 2. Record review of the face sheet, dated 12/16/23, revealed Resident #91 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body) and UTI (infection of the urinary system, usually caused from bacteria). Record review of the quarterly MDS assessment, dated 11/07/23, revealed Resident #91 had clear speech and was understood by staff. The MDS revealed Resident #91 was able to understand others. The MDS revealed Resident #91 had a BIMS of 8, which indicated moderately impaired cognition. The MDS revealed Resident #91 had inattention and disorganized thinking behaviors that fluctuated. The MDS revealed Resident #91 had an indwelling catheter. The MDS revealed Resident #91 had an active diagnosis of UTI during the last 30 days. Record review of Resident #91's comprehensive care plan, revised 11/06/23, did not address risk for UTIs or monitoring for signs or symptoms of an UTI. Record review of the nursing progress notes, dated 10/03/23, revealed Resident #91 was admitted to the hospital with a diagnosis of sepsis. No further documentation in the nursing progress notes regarding change of condition. Record review of the physician progress note, dated 10/02/23, revealed Resident #91 had increased confusion, fatigue, and weakness. The progress note revealed symptoms started on 10/01/23 with decreased food intake, loose stools, increased temp, dysuria, and dizziness. The progress note revealed Resident #91 was sent to the ER for evaluation and treatment. Record review of the admission history of physical completed by the hospital, dated 10/03/23, revealed Resident #91 presented to the ER with complaints of increased weakness, question of altered mental status, decreased oral intake, and temperature. Labs were obtained in the ER and his lactic acid level was elevated, which indicated Resident #91 was septic. The principal problem was sepsis, and he was started on antibiotics and placed on telemetry (monitors heart function). 3. Record review of the face sheet, dated 12/15/23, revealed Resident #107 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses which included Congestive heart failure (also called heart failure is a serious condition where the heart doesn't pump blood as efficiently as it should), cerebral infarction (a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hypertension (high blood pressure), and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar (glucose). Record review of the quarterly MDS assessment, dated 10/03/23, revealed Resident #107 was able to understand and understood by others. The MDS assessment revealed he had a BIMS score of 12, which indicated moderately impaired cognition. The MDS did not indicate if he required help with his ADLs. The MDS indicated he was frequently incontinent of bowel and bladder. Record review of Resident #107's comprehensive care plan, dated 12/11/23, indicated Resident #107 was at risk for UTI related to bladder incontinence. The interventions were for staff to give antibiotics as ordered, check, and change as required for incontinence care, and encourage fluids. The comprehensive care plan, dated 02/10/23, indicated Resident #107 had an ADL self-care deficit related to activity intolerance, general weakness, and cognitive impairment. The interventions were for 1 staff to assist with extensive assistance with toilet use. Record review of the order summary report, dated 12/15/23, revealed Resident #107 had an order, which started on 12/11/23 for ciprofloxacin (antibiotic) x 10 days for an UTI. No orders were in the system for contact isolation precautions. Record review of the MAR, dated December 2023, revealed Resident #107 had been taking antibiotics for a UTI since 12/08/23. Record review of the nursing progress note, dated 12/07/23, revealed Resident #107 had complained of increased frequency and urgency with urination. The NP was notified, and new orders were received for UA with C&S, stat. Record review of Resident #107/s nursing progress note, dated 12/08/23, revealed the NP was in the facility reviewing labs and a new order was obtained for Bactrim DS x 7 days because bacteria was present in the urine. Record review of the nursing progress note, dated 12/11/23, revealed Resident #107 was seen by the NP. New orders were given to discontinue the Bactrim DS (antibiotic) and start Cipro x 10 days for UTI. Record review of the nursing progress note, dated 12/14/23, revealed Resident #107 was temporarily moved to a single occupancy room related to infection requiring contact isolation. Record review of the lab results, reported 12/11/23, revealed Resident #107 was positive for ESBL (resistant bacteria that requires isolation precautions) in his urine. During an observation on 12/11/23 at 9:17 a.m., CNA PP was providing incontinent care to Resident #107. CNA PP explained what she was going to do and pulled the curtain. She wiped his genitals area using a front-to-back and back-to-front motion. She then turned him on his side while touching his shoulder and side with the same dirty gloves on. She proceeded to wipe his buttocks using the front-to-back and back-to-front motions. She then changed her gloves without hand hygiene and applied his briefs and clothes. She then removed her gloves and assisted Resident #107 up in his wheelchair. CNA PP then left the room without hand hygiene. During an interview on 12/11/23 at 10:54 a.m., CNA PP said she had been employed at this facility for almost a year. She said she was supposed to wipe front to back only, hand hygiene before applying new gloves, and in between dirty to clean. She said she did not wipe or perform hand hygiene correctly which could lead to infection. She said she was in a hurry to finish because she was helping another aide so she could get back to her assigned residents. 4. Record review of the face sheet, dated 12/15/23, revealed Resident #111 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnosis of UTI (infection of the urinary system that is usually caused by bacteria). Record review of the quarterly MDS assessment, dated 12/01/23, revealed Resident #111 had clear speech and was understood by staff. The MDS revealed Resident #111 was able to understand others. The MDS revealed Resident #111 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed Resident #111 had an indwelling catheter. Record review of the comprehensive care plan, revised, 10/02/23, revealed no care plan in place for UTI. Record review of the order summary report, dated 12/15/23, revealed Resident #111 had an order, which started on 12/01/23, for Linezolid (antibiotic) x 14 days for UTI. No orders were listed for isolation precautions. Record review of the MAR, dated December 2023, revealed Resident #111 had been taking antibiotics for an UTI since 12/02/23. Record review of the lab results, reported 12/01/23, revealed Resident #111 had critical results for positive culture of VRE (resistant organism found in urine which requires contact isolation precautions). Record review of the physician progress note, dated 12/04/23, revealed Resident #111 was positive Enterococcus faecium (bacteria) and was started on antibiotics. The progress notes did not state isolation precautions were initiated. During an observation and interview on 12/15/23 at 8:04 a.m., surveyor walked into Resident #107's room and saw the facility staff had moved him to another room. His roommate stated they moved Resident #107 last night (12/14/23) at about 8:00 pm. His roommate said people came into the room in all the gear and took him out. During an observation on 12/15/23 at 8:16 AM Resident #107 and Resident #111 had moved to another hall. They both had carts set up outside their rooms (containing gowns, gloves, face shields, and red biohazard bags) and precautions signs on their doors. During an interview on 12/15/23 at 8:49 a.m., CNA PP said she was not aware of any infection Resident #107 had until today (12/15/23). She said she had worked with Resident 107 on Monday (12/11/23) and Thursday (12/14/23) without any PPE because she was unaware of any isolation precautions needed. During an interview on 12/15/23 at 8:54 a.m., Housekeeper VVV said she worked on halls 300 and 400 Tuesday (12/12/23), Wednesday (12/13/23), and Thursday (12/14/23) and was not aware of any isolation required for Resident #107 or Resident #111. She said she had not worn any PPE that week while cleaning the rooms. She said she was informed late yesterday (12/14/23) about both residents who required isolation and she was supposed to wear PPE while cleaning those rooms. During an interview on 12/15/23 at 9:11 a.m., RN AAA said she worked Monday (12/11/23) on halls 300 and 400. She said she worked with Resident 107 and Resident #111 and was not aware they required isolation. She said she received in shift report that they were both on antibiotics for UTI. She said mostly the NP reviewed the labs and gave orders. She said she just went off whatever the NP said. She said if she had seen the labs then she would have notified the doctor, family, and DON. She said she would gather the PPE needed for that room. She said they usually did not write orders for isolation unless it was an order. She said without them isolating residents who required isolation, she could see where infection could be spread. During an interview on 12/16/23 at 2:38 p.m., LVN CC said she was the nurse who received Resident #111's lab report and notified the NP but was not aware that VRE required isolation. She said the NP gave orders for an antibiotic but never said this resident required isolation. She said she was not aware Resident #107 had ESBL. She said she was the nurse who first collected his urine because he complained of urgency. She said then she was off for two days and when she came back, she realized he had started on another antibiotic but did not think much about it because, in the shift report, she was told he had a UTI. 5. Record review of a face sheet dated 12/16/2023 indicated Resident #330 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included enterocolitis due to clostridium difficile, not specified as recurrent (Infection of the colon caused by the bacteria Clostridium difficile). Record review of Resident #330's electronic health record on 12/16/2023 indicated her MDS assessment was in progress. Record review of the Admission & Baseline Care Plan/Summary with an effective date of 12/09/2023 indicated Resident #330's reason for admission/initial admission goals were weakness, pneumonia, C. diff (clostridium difficile). The Admission & Baseline Care Plan/Summary indicated Resident #330 had a current diagnosis of C. diff and required contact precautions. Record review of the Order Summary Report dated 12/11/2023, did not indicate Resident #330 was on contact precautions. Record Review of Resident #330's After Visit Summary dated 12/8/2023 indicated continue precaution active isolation orders contact enteric precautions continuous. During an observation and interview on 12/11/2023 at 10:16 AM, Resident #330 was lying in bed. Resident #330 said she had recently admitted from the hospital. Resident #330 said while in the hospital she had been told he had C. diff. There was no sign posted on the door indicating Resident #330 was on contact precautions. There was a plastic bin with PPE inside Resident #330's room at the foot of the bed. Surveyor entered the room with no PPE. During an observation on 12/11/2023 at 10:28 AM, RN D took Resident #330 water and assisted her with drinking it. RN D went in Resident #330's room with no PPE. During an observation on 12/11/2023 at 10:46 AM, there was a sign on Resident #330's door indicating she required contact precautions and everyone must clean their hands including before entering and when leaving the room, providers and staff must also put on gloves before room entry, discard gloves before room exit, put on gown before room entry, discard gown before room exit, do not wear the same gown and gloves for the care of more than one person, use dedicated or disposable equipment, clean and disinfect reusable equipment before using on another person. There was a plastic bin with PPE outside the room and a regular trashcan. During an interview on 12/11/2023 at 10:55 AM, RN D said when Resident #330 arrived from the hospital she only had one day left on contact precautions. RN D said Resident #330 no longer required contact precautions, and she had even had a visitor over the weekend in the room with no PPE. RN D said she did not even think Resident #330 really had C. diff because she had smelled her stool. During an interview on 12/14/2023 at 5:05 PM, the Infection Control Preventionist said Resident #330 was admitted from the hospital with C. diff. The Infection Control Preventionist said the charge nurse who admitted a resident requiring precautions was responsible for ensuring the precautions were put in place. The Infection Control Preventionist said the charge nurse should have placed a sign on the door, and an isolation cart outside of the door and ensured all the staff were aware the resident required special precautions. The Infection Control Preventionist said Resident #330 should have had an order for contact precautions. The Infection Control Preventionist said the staff and visitors should wear PPE when in Resident #330's room. The Infection Control Preventionist said ultimately it was her responsibility to ensure the contact precautions were in place. The Infection Control Preventionist said it was important to ensure contact precautions were in place for Resident #330 to prevent the spread of infection to the residents and the staff. During an interview on 12/14/2023 at 5:31 PM, LVN G said she was supposed to admit Resident #330, but Resident #330 arrived at the end of her shift. LVN G said she was aware Resident #330 required contact precautions because she had C. diff. LVN G said she had put the isolation cart and a trashcan outside of Resident #330's room. LVN G said she had not put up a sign on Resident #330's door to alert staff and visitors that Resident #330 required contact precautions. LVN G said she did not know what happened that the isolation cart with the PPE was not outside Resident #330's room Monday morning (12/11/2023). LVN G said Resident #330 not having contact precautions in place placed people and residents at risk of catching what she had. During an interview on 12/15/2023 at 8:35 AM, Housekeeper H said she used K-Quat (disinfectant cleaner) to clean and mop the rooms. Housekeeper H said she had not been putting on PPE to clean any resident rooms. Housekeeper H said the staff would let her know if someone required special precautions. Housekeeper H said she used the same cleaning supplies to clean all the rooms even the ones that required special precautions. During an interview on 12/15/2023 at 8:43 AM, Housekeeper K said none of the resident rooms required special cleaning. Housekeeper K said she was not wearing PPE in any of the resident rooms. Housekeeper K said she used K-Quat and Enzap to clean the residents' rooms. During an interview on 12/15/2023 at 9:05 AM, the Housekeeping Supervisor said K-Quat was the disinfectant they used. The Housekeeping Supervisor said there were no rooms that required special cleaning. The Housekeeping Supervisor said if a resident had C. diff the same cleaning products would be used. The Housekeeping Supervisor said it was important to use the correct cleaning agents so infection would not spread and to keep infections contained. During an interview on 12/15/2023 at 12:25 PM, CNA M said she had cared for Resident #330 over the weekend. CNA M said she was aware Resident #330 had C. diff. CNA M said when providing care to Resident #330 she did not wear PPE. CNA M said she had worn gloves and that was all. CNA M said she had not washed her hands with soap and water that she had used alcohol-based hand sanitizer. CNA M said it was important to follow contact precautions to prevent the spread of infection and make it safer for herself and everybody else she provided care for. During an interview on 12/16/2023 at 5:10 PM, the ADON said she was not aware Resident #330 had C. diff. The ADON said they had 4 admissions Friday (12/08/2023) when Resident #330 admitted . The ADON said the nurses should follow the hospital discharge orders. The ADON said Resident #330 should have had an order for contact precautions. The ADON said an isolation cart should have been placed outside of Resident #330's room, a sign indicating she required contact precautions posted on her door, and a trashcan inside her room. The ADON said the nurses were responsible for putting Resident #330's contact precautions in place. The ADON said not having the contact precautions in place placed the residents and staff at risk for infection. During an interview on 12/16/23 at 6:41 PM, the DON said she had not reviewed Resident #330's discharge orders until Monday. The DON said she expected for the nurses to place a resident with C. diff on contact precautions. The DON said the admitting nurse should have put in the discharge orders from the hospital. The DON said the Infection Control Preventionist was responsible for overseeing that the nurses were putting necessary precautions in place. The DON said ultimately, she was responsible for ensuring the Infection Control Preventionist was putting measures in place. The DON said it was important to ensure precautions were in place as required to prevent the spread of infection. 6. During an observation of medication administration beginning on 12/12/2023 at 8:12 AM, MA A administered medications to Resident #40. After administering medications to Resident #40 MA A did not perform hand hygiene. MA A administered medications to Resident #2. MA A did not perform hand hygiene prior to preparing meds for Resident #2. MA A did not perform hand hygiene after administering medications to Resident #2. MA A administered medications to Resident #16. MA A did not perform hand hygiene prior to preparing medications for Resident #16. MA A performed hand hygiene after administering medications to Resident #16. During an interview on 12/12/2023 at 12:20 PM, MA A said she thought it was every third resident that she had to hand sanitize. MA A said she did not perform hand hygiene appropriately because she was not sure when to perform hand hygiene. MA A said it was important to perform hand hygiene to make sure no germs go on to the next resident. MA A said she had just started working at the facility in September or October 2023 because she had just received her license in April 2023. MA A said she had a check off done on hand hygiene when she started. During an interview on 12/16/2023 at 5:05 PM, the ADON said during medication administration hand hygiene should be performed before and after. The ADON said she had performed the check off for MA A and she had done fine. The ADON said she monitored the staff to ensure they were performing proper hand hygiene by walking the halls daily several times a day. The ADON said it was important to perform hand hygiene to prevent the spread of infection. During an interview on 12/16/2023 at 6:47 PM, the DON said she had instructed MA A to use alcohol hand sanitizer between residents and soap and water every third resident. The DON said clearly MA A had misunderstood. The DON said hand hygiene should be performed before and after medication administration. The DON said everybody was held accountable for performing hand hygiene. The DON said ultimately nursing management monitored through observations daily to ensure the staff were performing adequate hand hygiene. The DON said during her observations she had not noticed any issues with hand hygiene. During an interview on 12/16/2023 at 7:53 PM, the Administrator said everybody in the building was responsible for ensuring hand hygiene was performed. The Administrator said he expected for the staff to follow the policy on hand hygiene. The Administrator said not performing adequate hand hygiene during medication administration placed the residents at risk for infections and dirty meds. 7. Record review of Resident #68's face sheet dated 12/14/2023, indicated Resident #68 was a [AGE] year-old male admitted to the facility on [DATE], with diagnosis which included unspecified sequelae of cerebral infarction (residual effects or conditions produced after the acute phase of an illness or injury has ended), type 2 diabetes mellitus without complications (closely manages their type 2 diabetes, they can reduce their risk of developing any complications), hypertension (when the pressure in your blood vessels was too high (140/90 mmHg or higher). Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated Resident #68 had a BIMS score of 1, which suggest severe cognitive impairment. The MDS assessment indicated Resident #68 was always incontinent of bowel and bladder. Record review of Residents #68's care plan last revised 10/2/2023, indicated Resident #68 received extensive assistance with toilet use. During an observation on 12/14/2023 at 5:14 p.m., CNA SSS provided incontinent care to Resident #68. CNA SSS washed her hand, put on gloves, and unfastened Resident #68's brief. CNA SSS wiped Resident #68's front perineal area, CNA SSS tucked the dirty brief under Resident #68, turned Resident #68 onto his side and wiped his buttocks. CNA SSS then applied a clean brief without changing her gloves or performing hand hygiene. CNA SSS rolled Resident #68 to his side to remove soiled bedding and replaced with clean bedding. CNA SSS repositioned resident # 68 in the bed, removed her glove and performed hand hygiene. CNA SSS did not change her gloves or perform hand hygiene before going from dirty to clean. During an interview on 12/14/2023 at 5:45 p.m., CNA SSS stated hand hygiene should be performed prior to the start of care and at the end. CNA SSS stated hand hygiene should be performed after glove removal. CNA SSS stated she was new, just got nervous and forgot to change her gloves. CNA SSS stated it was important to provide proper incontinent care, so the residents did not get an infection. CNA SSS stated it was important to perform hand hygiene appropriately for infection control and to not spread germs. During an interview on 12/16/2023 at 11:58 a.m., the ADON stated she expected the CNAs to know how to provide incontinent care correctly. The ADON stated it was important to do incontinent care correctly to prevent infection, yeast, or UTI. The ADON stated she would monitor by doing check off's and in-service as needed. The ADON stated the harm to the resident was infection. During an interview on 12/16/2023 at 5:34 p.m., the DON stated she expected the CNAs to provide incontinent care correctly and with dignity. The DON stated it was important to do incontinent care correctly to prevent infection and any dignity issues. The DON stated she would monitor by doing in-service as needed, check offs, and 3 to 4 monthly random check off audits. The DON stated the harm to the resident was infection or psychosocial wellbeing. During an interview on 12/16/2023 at 6:10 p.m., the Administrator stated that it would be fantastic if the CNAs performed incontinent care correctly. The Administrator state[TRUNCATED]

Based on interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #54) of 3 resident reviewed for pressure ulcer. The facility failed to prevent Resident #54 from developing 2 unstageable pressure ulcers. The facility's failure could affect the prevention of pressure ulcers, affect residents with pressure ulcers, and put them at risk for worsening the wound and infection. Findings included: Record review of Resident #54's face sheet, dated 12/16/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included cerebral infarction (a lack of adequate blood supply to brain cells deprived them of oxygen and vital nutrients which can cause parts of the brain to die off), hypertension (high blood pressure), and Bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of Resident 54's quarterly MDS assessment, dated 10/31/23, indicated Resident #54 was understood and understood by others. The MDS assessment indicated he had a BIMS score of 15 indicating his cognition was intact. The MDS did not indicate Resident #54 refused care. The MDS indicated he required maximal assistance with toileting, bathing, dressing and hygiene, and set-up assistance with eating. The MDS indicated he had a stage 3 pressure ulcer. Record review of Resident #54's comprehensive care plan, dated 06/22/23 indicated Resident #54 had the potential for complications related to a left femur fracture. He had an immobilizer placed for protection and healing of his fracture. The interventions were for staff to assess the integrity of his skin daily. Record review of Resident #54's comprehensive care plan, dated 06/27/22, indicated Resident #54 had the potential for pressure ulcer development related to impaired mobility, cognition, and incontinent episodes. The interventions were for staff to check skin weekly, utilize heel boots when not ambulating or transferring, and assist with repositioning or turning to provide pressure relief. Record review of Resident #54's comprehensive care plan, dated 10/05/23, indicated Resident #54 was participating in the IV infusion program for wound healing. The interventions were for staff to give IV therapy as ordered. Record review of Resident #54's weekly skin report documented by LVN WWW dated 06/16/23 indicated, Resident #54 had an abrasion on the left calf from the immobilizer brace rubbing. Resident #54 also had a blister on the left outer ankle. Record review of Resident #54's nurse note documented by LVN RR dated 6/20/23 indicated Resident #54 was noncompliant with his immobilizer. The nurse noted his immobilizer was totally off his Left lower extremity. The nurse inquired; the resident admitted to removing the device stating it was too tight. Resident educated per nurse. Will continue to monitor. Record review of Resident #54's wound care assessment note documented by wound care NP dated 6/21/23 indicated, an unstageable to left lower leg measuring 6.5X1.0X2.0cm and unstageable to left outer ankle measuring 1.0X2.0X1.5cm. Record review of Resident #54's physician orders dated 06/22/23 indicated: Cleanse with Normal Saline, pat dry, apply betadine, cover with non-adhesive foam, and wrap with an ace bandage every day shift (did not indicate a specific area). Record review of Resident #54's physician orders dated 07/01/23 indicated: Cleanse with Normal Saline, pat dry, apply betadine, cover with non-adhesive foam, and wrap with ace bandage every evening shift (did not indicate a specific area). Record review of Resident #54's physician orders dated 08/10/23 indicated: Cleanse left lower extremity with Normal Saline, pat dry, apply betadine, and leave open to air every evening shift. Record review of Resident #54's physician orders dated 08/11/23 indicated: Cleanse left outer ankle with Normal Saline, pat dry, apply Thera honey, and cover with dry dressing every day shift. Record review of Resident #54's physician orders dated 08/23/23 indicated: Cleanse left outer ankle with normal saline, pat dry, apply Thera honey, and cover with dry dressing every evening shift. Record review of Resident #54's physician orders dated 10/25/23 indicated: Cleanse left outer ankle area with Normal Saline or wound cleanser, pat dry, apply collagen, and cover with dry dressing daily and as needed. Record review of Resident #54's physician orders dated 10/31/23 indicated: Cleanse Left lower leg with Normal Saline or Wound Cleanser, pat dry, apply Collagen, and cover with dry dressing daily till healed. Record review of Resident #54's physician orders dated 11/08/23 indicated: Cleanse Left lower leg with Normal Saline and apply betadine. Leave open to air daily. Record review of Resident #54's physician orders dated 11/15/23 indicated Wound care: Apply Skin-Prep to left lower leg every day x1 week. Monitor for s/s of infection. Record review of Resident #54's weekly skin report dated 11/22/23 indicated, Resident #54's wounds had healed. During a phone interview on 12/14/23 at 12:51 p.m., the Wound Care NP said she had seen Resident #54 for at least 8 weeks. She said he had a fracture and his orthopedic doctor recommended he wear a brace. She said she felt the 2 open areas to the left lateral leg and left ankle were caused by the leg immobilizer. She said Resident #54 had to wear the brace because of the non-surgical fracture. As soon as they were able to remove the brace, they were able to make better progress in healing the wounds. During an attempted phone call on 12/14/23 at 1:05 p.m., a message was left for the previous treatment nurse. During an attempted phone call on 12/14/23 at 3:29 p.m., a message was left for the orthopedic doctor. During an interview on 12/14/23 at 3:31 p.m., RN AAA said she was resident #54's nurse most days. She said she remembered Resident #54 had 2 pressure injuries but could not remember why he had them or how he got them. She said he had an immobilizer related to the fracture he had but could not remember how long he had the immobilizer. She said she does remember checking for circulation and making sure it was not too tight but she never opened the immobilizer to look at his skin. She said she should check under the device to inspect the skin to prevent sores. During an interview on 12/14/23 at 4:41 p.m., Resident #54 said he was trying to play with the facility dog, lost his balance, and fell . He said he had an immobilizer on his left leg, he did remove it from time to time, because it rubbed his leg. He said he wore the brace for several months. He said he had 2 sores on his leg but was unaware of how he obtained them. He said they were healed now. During an interview on 12/14/23 at 6:18 p.m. the facility NP said Resident #54 obtained the 2 pressure injuries from the immobilizer. She said they did an IV infusion to help with the wound healing. She said he had to wear the immobilizer to heal his non-surgical fracture. She said the facility should have had interventions in place and checked his skin daily. She said that when they did identify a problem, they notified her, and she consulted with the wound care NP. During an interview on 12/16/23 at 1:50 p.m., the ADON said Resident #54 received some pressure ulcers from his immobilizer. She said she was unaware if an order had been placed to monitor his skin daily after receiving the immobilizer. She said the nurses should have been monitoring his skin daily. She said they would implement daily checks for any splint/immobilizers going forward to help prevent skin breakdown. During an interview on 12/16/23 at 2:38 p.m., the DON said Resident #54 developed pressure ulcers from his immobilizer. She said staff were monitoring his skin weekly. She said when they identified he had opened areas they implemented treatment. She said they should have placed an order to check his skin daily once he received the immobilizer, but they did not. She said failure to check under an immobilizer daily could cause skin issues. She said his pressure ulcers were healed now. During an interview on 12/16/23 at 5:34 p.m., the Administrator said he was told Resident #54 developed his pressure ulcers from the immobilizer. He said it was probably not fitting properly but he really could not say what caused the wounds. He said the clinical team was responsible for ensuring his skin remained intact. During an interview on 12/16/23 at 6:00 p.m., the Director of Clinical Operations said they did not have a policy on immobilizers or developing wounds. Record review of the facility policy, Wounds care, dated 10/2010, indicated, The purpose of this procedure was to provide guidelines for the care of wounds to promote healing.

Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 of 6 residents (Resident # 1) reviewed for accidents and supervision. On [DATE] Resident #1 eloped from the facility and was found by facility staff on [DATE] approximately 30 feet from the facility deceased This failure placed all residents at risk for accidents, harm, and possible death. An (IJ) Immediate Jeopardy was identified on [DATE] at 5:00pm. While the (IJ) Immediate Jeopardy was removed on [DATE] at 2:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy identified because all staff had not been trained on Abuse/Neglect, documentation, care plans, elopements and the effectiveness of their systems. Findings included: Review of Resident #1 face sheet dated [DATE], reflected Resident # 1 was a 66- year- old man, admitted to the facility on [DATE]. Resident # 1 was diagnosed with Vascular Dementia (general term describing problems with reasoning, planning, judgement, memory and other thought process caused by brain damage), Traumatic Subdural Hemorrhage (intercranial bleeding between the brain and the skull), Alcohol abuse (a pattern of drinking that interferes with day-to-day activities), Homelessness (individual with no permanent living arrangement), Muscle weakness ( when full effort doesn't produce a normal muscle contraction or movement), Cognitive Communication Deficit (difficulty with thinking and how someone uses language), and Hypokalemia ( low levels of potassium in your blood). Review of Resident # 1 admission MDS dated [DATE] reflected a BIMS score of 10, the resident has the cognitive ability to make his needs known. Section G of the MDS functional status reflected Resident # 1 required (supervision, oversight or cueing) with bed mobility, transfers, walk in room, walk in corridor, eating and dressing. Section GG of the MDS Functional abilities reflected Resident # 1 was independent with putting on/taking off footwear and oral hygiene. Review of Resident # 1 care plan dated [DATE] did not address any elopement /wandering behaviors. The care plan addressed discharge planning which reflected Resident # 1 would stay at the facility long term. Observation on [DATE] at12: 45 pm, reflected in Resident # 1's previous room [ROOM NUMBER] the window hinges were observed to be broken off. During an interview on [DATE] at 9:20am with LE, revealed that Resident # 1 was found near the facility on [DATE] deceased . He stated during their search of Resident # 1, that this area was searched they did not think that he was in this area at the time they were searching. He stated the judge did order that an autopsy be completed. He stated the decompensation of Resident # 1 showed that he had been deceased for more than six hours, less than three days factoring in the weather conditions the past few days. LE stated they did not suspect any foul play, stated it appeared that the resident fell and was unable to get back up. During an interview on [DATE] at 12:30pm with, Resident # 2 revealed, Resident # 1 had recently broke the hinges off the window in their room, raised the window and put his wheelchair outside the window. He stated Resident # 1 also had put all his things in trash bag. Resident #2 stated he had moved to another to the 300 hall maybe a week ago but stated he would walk back and forth to the old room with his things in is hand. He stated Resident # 1 did not talk much so he never stated that he was leaving, but he had packed up his things like he was leaving. During an interview on [DATE] at 12:50pm with Maintenance supervisor revealed, he was not able to remember the exact date, but stated he pulled up to the facility and saw that there was a wheelchair outside Resident # 1 window. He stated he got the wheelchair and stated Resident # 1 stated he did not want the chair in his room. He stated he was not aware that the hinges were broken on the window, until shown by surveyor. He stated they were in the process of replacing all the window screens on the windows at the facility. Maintenance director stated he and the social worker went to Resident #1's room and he stated again he was not using the wheelchair and did not want the chair in his room. The Maintenace supervisor reported that one of her workers was dumping rash and he smelled an odor that wasn't coming from the trash. He stated his worker came and got him and they got the tr uck back it up in the tall brush, stood in the bed of the truck and that;s when they found Resident # 1 deceased lying in the middle of the tall brush. During an interview on [DATE] at 1:15pm with maintenance worker reported dumping trash in the back dumpster and smelled a foul odor that wasn't coming from the dumpsters. Maintenance worker stated he walked closer to the area and the odor got stronger, he stated he then went and got the maintenance director and they backed t he truck up where the bushes were and stood in the inside the bed of the truck to look and that's when they discovered Resident #1 lying on the ground and appeared to be deceased . Maintenance worker stated they alerted the DON and the ADM, and contacted the police at that time During an interview on [DATE] at 1:29pm with CNA A, revealed Resident # 1 was seen on [DATE], that morning around 10:00am when she picked up his breakfast tray. She stated she observed Resident # 1 standing by the back door looking out the door, she stated he then returned back to his room on the hall 300. During a phone interview on [DATE] at 2:24pm with MA A, revealed A few weeks prior to the incident Resident # 1 had an incident in his previous room on Hall 400. MA A stated Resident # 1 had opened his window and put his wheelchair out the window. MA A stated on the day of the incident she last saw Resident # 1 around 11:00am when she took residents out to smoke. She stated prior to that Resident # 1 did not appear to be exit seeking. During an interview on [DATE] at 2:34pm with DON, revealed Resident # 1 did have an incident where he opened his room window on the 400 hall and put his roommate's wheelchair out the window. She stated the social worker should have documented this information in the progress notes of the incident. The DON stated she was not aware that the hinges on that window had been broken and not replaced, she stated she also was not aware that the screen had not been replaced at this time. The DON was not aware of the specific date of that incident. The DON stated a wander/elopement assessment was not completed after this incident because Resident # 1 did not show any signs of elopement or agitation. The DON stated Resident # 1 was not assessed for wander/elopement risk after he completed therapy because they do them quarterly and it was completed on [DATE]. In an interview on [DATE] at 3:00pm with ADM., revealed that he thinks he was on vacation during that time of the incident. The ADM. stated he was told about the hinge on the window this morning and maintenance is working on fixing that now. Stated they are replacing all the screens on all the windows at the facility. He stated he did think that Resident #1 was safe and able to go on an outing the building without supervision. The ADM. stated after Resident # 1 completed therapy there was no reason to complete wander/elopement assessment because he had not shown any signs of elopement and wander /elopements assessments are completed quarterly. During an interview on [DATE] at 6:06pm with Director of Rehabilitation, revealed Resident # 1 had completed OT (Occupational therapy) and PT (physical therapy) on [DATE]. She stated Resident # 1 was independent with ADL's (activities of daily living), Resident # 1 was ambulatory. Director of Rehabilitation was asked if an elopement assessment was completed at this time for Resident # 1since he was now independent she stated she was not aware that one had been completed. During a phone interview on [DATE] at 11:05am with PNP, revealed that she could not recall specifically what was said in the conversation, but she recalled that the facility called her regarding Resident #1 being agitated and that he had placed his wheelchair out the window. She stated that the specifics would be in her notes that she uploads to PCC. She stated that she did not have any concerns or complaints about resident care or about the facility. During an interview on [DATE] at 12:40pm with SOWK, revealed on [DATE] the Maintenance Director came and told her about the wheelchair sitting outside of a window. We went down to talk to Resident #1. The SOWK reported that when they got to the room Resident #1 was lying across the bed watching TV. She stated that she saw the window screen between the wall and the head of the bed, and the window was closed. She reported that she noticed the resident's clothing all bagged up and she asked him about it, and he told her it was how he wanted to keep them, and that he did not like using the drawers. She stated that the resident asked them to leave so he could watch mutherfucking [NAME]. She stated that she did ask him if there was any particular staff that he felt comfortable talking to if he had any issues or concerns and Resident #1 told her that he preferred to talk to the blond lady up by the office The social worked determined this to be staff from laundry. She stated that the resident denied thoughts or plans to elope. The SOWK stated that this behavior was not out of the ordinary for the resident and that he did walk around the facility with his personal items in hand at times. She stated that this incident with the wheelchair was reported to the Psychiatric nurse practitioner. She stated that after he completed therapy his cognition and physical state had improved from when he was first admitted . She stated that she had received in-service this past week on abuse, neglect, elopement. Reporting broken item, missing screen etc. to maintenance and heart injury. During an interview on [DATE] at 1:45pm with house-keeping, revealed she had been at the facility for about 2 ,d+[DATE] months. She stated that she knew Resident #1 from before he entered the facility. She reported that the resident would stay in the area where she lived on the streets and everyone in the neighborhood knew him. She reported that when he came into the facility, they helped find him some clothes and personal care items because he did not have anything. She stated that when he went missing, she thought he might have gone back to the neighborhood, so she drove around looking for him after work. She stated that Resident #1 had never talked about leaving and had never tried to leave that she knew of. She reported that he would walk around with his clothes, and she thought this was because of his history of being homeless. During an interview on [DATE] at 11:27am with SOWK, revealed Resident # 1 had an incident earlier in the month as could not remember the exact date where Resident # 1 opened his room window on the 400 hall and put his wheelchair out the window. She stated she and the maintenance supervisor went down to the resident's room and stated she observed Resident # 1 had his things packed in a clear bag, his window was open, but he was sitting on the bed when they arrived. SOWK stated Resident # 1 stated the wheelchair was in his way, she stated when she asked about his clothing being in the bag stated Resident # 1 responded by stating he liked them in the bag. SOWK stated she reported this information to the nursing staff and in the morning meeting about Resident # 1 behavior. She stated it was discussed and that's when the decision was made to move Resident # 1 to the 300 hall. SOWK was asked if Resident # 1 was moved due to him opening his window, packing his things, and placing his wheelchair outside the window, she stated no. SOWK stated Resident # 1 was moved to hall 300 because he and his roommate were not getting along. SOWK was asked if an elopement assessment was completed at the time of this incident she stated no. Weather website reviewed: https://weather.com/weather/monthly/l/dab66db432c15c4b458fc6dfaa6c73a5703d4aaa8bc36cb83356ed6c80af938cc2be9a97aa3b8d3b2d1f8a0033eff4c0. Reflected, the weather temperature for Waco on [DATE] was 99 degrees, [DATE] 101 degrees, [DATE] 101 degrees, and [DATE] 96 degrees outside. Review of Resident # 1 Risk elopement/wander assessments dated [DATE] that was provided later in the investigation had written, indicating Resident # 1 was low risk for elopement, [DATE] assessment, identified Resident # 1 as low risk for wandering /elopement. No assessment was completed after Resident # 1 incident and no assessment after completion of therapy services. Record review of progress notes dated from [DATE] - [DATE] reflected, reflected no exiting behaviors. The progress notes do not reflect the incident where Resident # 1 opened his window and put his wheelchair outside his window or that he had his things packed in a bag. Review of facility Elopement policy dated [DATE] reflected the following: 1. Upon admission and re-admission residents will be assessed for elopement risk in conjunction with the nursing admission data collection. 7. Following admission, residents are evaluated for elopement risk quarterly, annually, and with significant change of condition. Review of facility Abuse/Neglect policy dated [DATE]reflected: Residents have the right to be free from abuse and neglect. The (IJ) Immediate Jeopardy template was delivered to the ADM on [DATE] at 5:00pm. While the (IJ) Immediate Jeopardy was removed on [DATE] at 2:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy because all staff have not been trained on Abuse/Neglect, documentation, care plans, elopements and the effectiveness of systems. Plan of removal submitted on ,d+[DATE] and accepted on [DATE] at 8:49am. The Plan of Removal is as follows: LETTER OF PLAN FOR REMOVAL OF IMMEDIATE JEOPARDY [DATE] On [DATE], a survey was initiated at facility, At approximately 5:00pm on [DATE], a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at the facility constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F689: The facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents and hazards. 1 resident was affected by this deficient practice. All residents could be affected by this deficient practice. Immediate Corrections Implemented for Removal of Immediate Jeopardy. On [DATE]nd, 2023, at approximately 6:00pm the following actions were taken: Action: Administrator and Director of Nursing received education on elopement policy and education for all direct care and ancillary staff (including housekeeping and dietary) given by Director of Clinical Operations. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Clinical Operations. Action: Education given by Infection preventionist and ADONs to all direct care (including agency) and ancillary staff (including housekeeping and dietary) on Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, including, packing items, statements of plans to leave, moving assistive devices to locations of exits. Education will be maintained at, agency shift worked, new hire orientation and annual refresher in-services. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/designee Action: Maintenance Director and Administrator checked windows on the 400 and 300 halls validated to be fully functional, screens replaced and secured. The screen on the 400 hall was replaced on [DATE]. No repairs were necessary to any latches on either window. All windows are in working order. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Action: Maintenance Director and Maintenance Tech secured all resident room windows to open no greater than 6 inches to prevent the potential of residents exiting via window Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: Action: Maintenance Director and Maintenance Tech completed sweep of all facility resident room windows, to validate windows are in functional repair and screens are in place to all resident room windows. 12 screens were replaced on [DATE]. No repairs were necessary to any latches on any window. All windows are in working order. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Action: ADONs and MDS Coordinators completed Elopement Risk Assessment on all residents and validated all residents at high risk of elopement, score of 11 or greater, have appropriate interventions and plan of care in place per risk assessment. After IDT interventions/care plan, those deemed to be high risk residents will have information placed in the elopement risk binder at the reception desk. Elopement Risk assessment is part of the Admission/Baseline care plan Summary completed on all new admissions by the charge nurse. This assessment is reviewed by DON/designee for completeness within 48 hrs of admission. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of nursing/designee Action: MDS Coordinators and Social Services completed sweep of all residents for history of homelessness, interviews completed and education on risks of homelessness, validation completed for any potential plans of exiting facility. Care plans updated to reflect IDT interventions for risks identified. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: ADONs and Infection Preventionist in-service and education was provided to all direct care (including agency) and ancillary staff (including housekeeping and dietary) and residents regarding the process for safe discharge as well as risks associated with heat exhaustion including signs and symptoms to watch for. Education will be maintained at agency shift worked, new hire orientation and annual refresher in-services. New residents will be educated on admissions by the admissions coordinator. Start Date: [DATE] Completion Date: [DATE] and ongoing until all staff have received education prior to their next scheduled shift. Responsible Party: Director of Nursing/Designee Action: Education to the Maintenance Director on the requirement to validate that windows are functioning properly and that screens are in place and in good repair. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Action: Education provided by Infection preventionist and ADONs to all direct care and ancillary staff (including housekeeping and dietary) on Elopement policy, Abuse/Neglect/Exploitation and reporting missing or broken windows and/or screens to their supervisor and/or maintenance staff. This will be reported immediately. Maintenance orders are placed in the TELs system that is linked to Point click care and point of care electronic medical record system. Start Date: [DATE] Completion Date: [DATE] and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing/Designee Action: Education was provided by Infection preventionist and ADONs to all direct care (including agency) and ancillary staff (including housekeeping and dietary) regarding new behaviors that must be reported to nursing which could indicate an increased risk or likelihood of imminent elopement attempt including but not limited to increased wandering, packing of belongings, verbalization of intent to leave, tampering with windows or doors and exit seeking. Additional education was provided to nursing staff on the expectation that these behaviors will be monitored/documented each shift as they occur by the charge nurse through the electronic medical record system in point click care. The elopement risk assessment and care plan will be updated within 24hrs by DON/designee. Education will be maintained at agency shift worked, new hire orientation and annual refresher in-services. Start Date: [DATE] Completion Date: [DATE] and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on [DATE] Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator/Designee Tracking and Monitoring Director of Nursing/Designee will review residents with High Risk for wandering or elopement identified or newly admitted with history of homelessness, to assure appropriate interventions and plan of care are in place 5 times per week beginning [DATE] for 4 weeks. Administrator/Designee will monitor windows for appropriate functioning, security, screens in place 5x/week beginning [DATE] for 4 weeks. Administrator/designee will complete random audit every shift for 7 days, beginning [DATE], for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week for 4 weeks. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee meeting monthly and continue until a lessor frequency deemed appropriate through QAPI review. The administrator and/or designee will be responsible for reporting any identified trends. Monitoring of Plan or Removal on [DATE] is as follows: Observation on [DATE] at 11:10am, observed facility window and screens are on all windows. Observation on [DATE] at 11:20am, observed windows in rooms on the 400 and 300 halls. Windows are fully functional, screens replaced, and secured. During an interview on [DATE] at 11:30am with Activity Assistant revealed, she has been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. Activity Assistant stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insisted on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. Activity Assistant stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. Activity Assistant stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 11:45am with LVN A, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. LVN A stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. LVN A stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. LVN A stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 12:12pm with RN revealed, she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. The RN stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The RN stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The RN stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 12:30pm with SOWK, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. The SOWK stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. The resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The SOWK stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The SOWK stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 1:30pm with the DON, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. She gave example of abuse, neglect, and exploitation. The DON stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and ADM. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The DON stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The DON stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. The DON stated that the facility identified 19 residents that are high risk for elopement. 18 of the residents are on the secured unit. The DON stated the elopement risk binder is kept at the front desk, if there is a questionable situation about their care refer to the binder or if a resident is missing a photo of every resident is located in the elopement risk binder. There was also a missing resident form in the binder for staff to complete if a resident was missing. During an interview on [DATE] at 2:15pm with CNA B, revealed she worked the day Resident # 1 opened his window and put his wheelchair outside the window. She stated they were informed right after the morning meeting by Resident # 1's roommate stated, Resident # 1 was very upset and wanted to leave the facility. CNA B stated that's when she, the SOWK and the maintenance supervisor went to Resident # 1's room. She stated the SOWK was able to calm Resident # 1 down and stop him from leaving that day. CNA B stated the Admin. was aware that Resident # 1 wanted to leave but nothing was done about, she stated she felt something could have been done about it, if the first incident had been documented. During an interview on [DATE] at 11:20am with ADM., he stated that management staff were present this weekend working on POR and staff education. He reported that the Regional Care Coordinator had worked with him and the DON and has completed their education on Elopement. The ADM. stated that Resident #1 had requested to stay in the facility long term and helped them complete the MEDICAID application. Observation completed on [DATE] at 11:45am, of windows observed in room on the 300 hall which is the room that Resident #1 was assigned to when he left the facility through the window. There was only one window in the room. The window was intact there is no damage around the casing to the wall. There was a cooling/heating unit in the wall just below the window. The locking mechanism was intact, the window was functional. There were screws placed internally to prevent the window from being raised greater than six inches. The screen is intake. The window opened to a small grassy area that meets the facility's rear parking lot. During an interview on [DATE] at 11:50am with the Maintenance Director, revealed he and his crew had checked all windows and screens this past week. He reported that the facility had ordered new solar screens and they would be replacing all screens with those when they arrive. He reported that he had not encountered any broken or damaged windows or window locks. There had been some screens with some small holes they had replaced. The Maintenance Director reported that he had in- serviced staff this week on putting in maintenance orders in the event they find something broken or that needed attention. He stated they could either text, call, come find him or put the work order into the TELS system which is connected to their electronic medical record (PCC). He stated they had performed test reports to demonstrate to staff how the order came across their phones. He stated that he had been serviced in the past and this week on elopement, abuse, and neglect. He also stated that they were in-serviced on heat-related injury. During an interview on [DATE] at 1:15pm with laundry aide, revealed she had been employed with the facility for [AGE] years. She stated that she had been in serviced on elopement, abuse and neglect, heat stroke and when to report broken things to maintenance this week. She stated that they are always doing some type of in-service. She denied any concerns or complaints regarding the facility or resident care or supervision. During an interview on [DATE] at 2:20pm with CNA C, revealed she had worked at the facility in her current position for about 4 years. She reported that they had been in serviced this week on abuse, neglect, heat injury. She denied any concerns or complaints about the facility. During an interview on [DATE] at 2:45pm with Resident # 2, revealed he had been at the facility since [DATE]. He stated that they treated him well other t [TRUNCATED]

Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #6) of 25 residents reviewed for quality of care. The facility failed to ensure Resident #6 skin condition which started as redness with 2-3 blisters on right buttocks on 08/12/21 did not worsen. The Nurse Practitioner failed to accurately assess, monitor, and treated the active skin condition. This failure placed residents at risk for pain, decreased quality of life, serious illness, decline in health condition, and increased risk for hospitalization . Findings included: Review of Resident #6's quarterly MDS Assessment, dated 05/03/21, revealed she was a [AGE] year old female who admitted to the facility on [DATE] with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a BIMS of 15 indicating she was cognitively intact. She required limited assistance of one staff for ADLs of bed mobility, transfers, dressing, toileting and hygiene. She was occasionally incontinent of bladder. Resident #6 had no current skin conditions. Review of Resident #6's Comprehensive Care Plan last care plan review completed 07/14/21 reflected the following: - Last revised 08/19/21 Resident #6 had an ADL self-care performance deficit related to impaired mobility, chronic pain syndrome, pain, [CONDITION(S)], magnesium deficiency, muscle spasms, cervical spondylosis, [CONDITION(S)], CHF [congestive heart failure], [CONDITION(S)]. Interventions included ADLs transfer with supervision and one person, toilet use with supervision and set up, observe/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. - Last revised 03/04/21 Resident #6 was incontinent of bowel and bladder related to impaired mobility and diuretic use. Interventions included clean peri-area after each incontinence episode, observe/document for signs and symptoms of [CONDITION(S)]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine .change in eating patterns. Review of Resident #6's Consolidated Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Start date of 08/12/21 of [MEDICATION(S)] powder apply to buttocks, hips, lower [NAME] topically two times a day for rash until clear. - Start date of 08/17/21 of [MEDICATION(S)] cream 0 unit/gram to buttocks, hips topically two times a day for rashes until healed. - Insertt Urethral Indwelling urinary catheter, 16F 30 cc due to [CONDITION(S)] with closed drainage system one time only for [CONDITION(S)] for 1 day. - Start date of 08/19/21 of [MEDICATION(S)] tablet 10 mg give 1 tablet by mouth one time a day for inflammation for 5 days. - Start date of 08/19/21 of Vitamin C Tablet give 500 mg by mouth two times a day for supplement for 30 days. - Start date of 08/19/21 of [MEDICATION(S)] tablet give 1 tablet by mouth one time a day for supplement for 30 days. Review of Resident #6's MAR/TAR for August 2021 reflected Resident #6 received the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 150 mg on 08/12/21 for rash and 08/14/21 for [MEDICATION(S)] infection. - [MEDICATION(S)] powder to buttocks, hip, lower back topically 2 times a day rash until healed from one time on 08/12/21 and two times each day from 08/13/21 to 08/18/21. - [MEDICATION(S)] cream 0 unit/gram to buttocks, hips topically on 08/17/21 one time and two times on 08/18/21. - Insert urethral indwelling urinary catheter, 16 F 30 cc due to [CONDITION(S)] with closed drainage system on 08/18/21. - [MEDICATION(S)] 10 mg on 08/19/21 for inflammation. Review of Resident #6's nurse notes reflected the following: - dated 08/12/21 by RN L reflected notified NP of resident chest x-ray results. Received order to start [Resident #6] on [MEDICATION(S)] 750 once daily 10 days and probiotics at noon for the duration of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . dated 08/12/21 by LVN O reflected Resident #6 had very bright red rash to buttocks, lower back with 2 blisters on right buttocks. New order received from NP for [MEDICATION(S)] mg one po now x1 dose. Given as ordered . UA (Urinalysis) collected. -dated 08/12/21 by LVN O reflected Resident #6 had a new order for [MEDICATION(S)] powder BID until clear. - dated 08/12/21 by LVN P reflected Resident #6 was started on [MEDICATION(S)] today for [CONDITION(S)]. [MEDICATION(S)] was given for [MEDICATION(S)] rash on buttocks. Resident denies pain at this time . -dated 08/14/21 by RN L reflected physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -dated 08/15/21 by LVN M reflected Resident #6 remains ABT [antibiotic therapy]/reddened buttocks with blistered and open area. Resident states [NAME] painful to the touch. Serosanguinous drainage noted on briefs and bed pad. [MEDICATION(S)] powder applied as ordered. Will cont. to monitor. Review of Resident #6's skin assessments reflected the following: - 08/09/21 signed by LVN C reflected Resident #6 had existing rashes to bilateral breast and abdominal fold. There was no rash to the buttocks. - 08/16/21 signed by LVN C reflected Resident #6 had existing bruises with description of blisters to bilateral buttocks with induration - 08/18/21 signed by RN L reflected Resident #6 had existing rashes to both buttocks and emerging to thighs. Treated with [MEDICATION(S)] powder. Nurse Practitioner gave order to consult with wound care clinic today. Observation and Interview on 08/17/21 at 2:50 PM revealed Resident # 6 was sitting in her wheelchair with a towel under her with no wheelchair cushion. Resident #6 stated she had redness and blisters on her bottom and stated she did not know what was causing it. She stated this was a new skin issue she had for the past week. She stated the facility staff are putting something on her bottom when they change her but not sure what. She stated it was painful to the touch and bothers her when sitting. She stated she did not have a wheelchair cushion and only had a towel to sit on. She stated it was uncomfortable to sit in her wheelchair and would like a cushion for her wheelchair. She stated she had a decline in her eating intake for the last couple of days and more tiredness for the last week. Observation and Interview on 08/18/21 at 12:20 PM revealed Resident #6 was sitting in her wheelchair with towel under her and had no wheelchair cushion. She was rocking back and forth in her wheelchair stating she was not comfortable. She stated she would like to lay in the bed and did not feel like eating anything for lunch today. Observation on 08/18/21 at 1:05 PM reflected CNA D and LVN I stood Resident #6 up to transfer her from the wheelchair to bed. The towel in the bottom of the wheelchair was stuck to her and towel was wet with urine. There was no wheelchair cushion. Observation of Resident #6's left, and right buttocks dermis denuded dark purplish red in color with small amount of blood on the towel. Interview of Resident #6 revealed she stated her bottom was painful when sitting or being touched. In an Interview on 08/18/21 at 1:20 PM with CNA D revealed she reported Resident #6's skin redness to her charge nurse (LVN I) last week and she took a photo. Interview on 08/19/21 at 9:40 AM with CNA D revealed she noticed Resident #6's redness with a couple of blisters on 08/12/21 and reported it to her charge nurse. She stated last Wednesday 08/11/21 Resident #6 only required supervision assistance in showering but on 08/13/21 she required two person assistance for showering and transfers due to not being able to stand up own and physical decline in assistance level. She stated Resident #6 did not eat her breakfast this morning. Interview on 08/19/21 at 1:55 PM with LVN I revealed on 08/12/21 CNA D got me and told me Resident #6 had a reddened bottom when she was showered. She stated she looked at Resident #6's bottom it was reddened with 2-3 water blisters on one buttock. She stated she contacted the Nurse Practitioner and sent her a picture of Resident #6 skin condition on 08/12/21. She was told by Nurse Practitioner she was already aware of Resident #6's rash from LVN O . She stated Resident #6 did not complain of any pain on 08/12/21 to her. She stated Nurse Practitioner came on Tuesday 08/17/21 but did not see Resident #6 or assess her skin condition. She stated Nurse Practitioner did not come to building on 08/18/21 to assess Resident #6's skin or see Resident #6. Interview on 08/19/21 at 3:30 PM with LVN M revealed on 08/15/21 Resident #6 did complain of pain to her buttocks with touch. She stated she medicated Resident #6 with pain medication as ordered. She stated she continued the orders of the [MEDICATION(S)] powder BID as ordered by Nurse Practitioner. Interview on 08/20/21 at 10:08 AM with LVN C revealed on 08/16/21 when she did Resident #6's weekly skin assessment she had scattered reddened and opened blisters on upper left and right buttocks. She stated it was an existing rash for Resident #6 and spoke with her Charge Nurse about it on 08/16/21. She stated Resident #6 had current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #6 denied any pain on 08/16/21. She stated Resident #6 was incontinent of bladder. She stated she did not know if Resident #6 had a cushion in her wheelchair. Interview on 08/19/21 at 3:38 PM with Rehab Director revealed she was not aware Resident #6 did not have a wheelchair cushion and no one had informed her Resident #6 needed one. She told Resident #6 she could come and tell her if she needed a wheelchair cushion. She stated she will look into getting a wheelchair cushion for Resident #6 so it is more comfortable for her when she is sitting in her wheelchair. Interview on 08/19/21 at 1:22 PM with RN L revealed on 08/17/21 she was doing the wound care for Resident #6 and stated she was concerned about Resident #6's existing redness and open area of rashes to both buttocks and emerging to thighs. She stated the [MEDICATION(S)] powder was not staying on Resident #6, so she contacted Nurse Practitioner on 08/17/21 over the phone who gave a new order to order [MEDICATION(S)] cream BID for the rash. She stated Resident #6 having a wheelchair cushion would help her be more comfortable especially with resident having a rash on her buttocks. She stated she did not know if the rash was worsening since 08/17/21 was the first time she looked at Resident #6's skin. She stated Nurse Practitioner did not assess Resident #6's skin on 08/17/21 and only gave a verbal order. Interview on 08/20/21 at 10:24 PM with LVN C revealed Nurse Practitioner came to facility on Tuesdays and was last at facility on 08/17/21. In an Interview on 08/18/21 at 2:25 PM with Nurse Practitioner revealed she had not assessed or seen Resident #6's buttocks. She has been in contact with the nursing department and gave verbal orders to treat previous [MEDICATION(S)] infection. A description of her buttocks was given to her by surveyor and Nurse Practitioner then stated she will order a foley catheter for Resident #6 and a wound care physician to evaluate her. Review of Resident #6's nurse note dated 08/18/21 by LVN I reflected NP making rounds in facility assessing rash to buttock new order 1 dose of [MEDICATION(S)] 1 g im [Intramuscular], chest x-ray to follow up from 08/12/21, [MEDICATION(S)] 10 mg qd [once a day] x 5 days, [MEDICATION(S)] 220 mg qd x 30 days, vit C 500 mg bid x 30 day, liquid protein 30 me l ml qd x 30 days, original scheduled and prn [MEDICATION(S)] order on hold x 7 days, give [MEDICATION(S)] 50 mg 2 tabs q [every] morning and night with 1 tab at 2 pm x 7 days, bnp, cbc, cmp routine, insert foley cath, refer to wound care . In an Interview on 8/19/21 at 4:23 PM with Nurse Practitioner revealed she did not come to the facility to assess Resident #6's skin condition on 08/18/21. She gave verbal orders yesterday on 08/18/21 via phone. She did receive a photo from a facility nurse when she ordered the [MEDICATION(S)] dose the first time on 08/12/21. She stated she does not come in every day to the facility she has other facilities. Observation and Interview on 08/19/21 at 9:43 AM with Resident #6 revealed she was lying in bed with foley catheter . Resident #6 stated she did eat her breakfast this morning. Review of Resident #6's Nurse Note dated 08/19/21 at 17:25 reflected Resident #6 had increased tremor, more shortness of breath, wheezing, Oxygen saturation at 93% on 3 liters oxygen via nasal cannula. Advised resident of concerns about her condition. BP within normal limits. Resident stated she would go to hospital to get evaluated. Nurse Practitioner was called to obtain order to transfer resident for further evaluation and treatment. Called ambulance to transfer resident. Resident requested to go to hospital. Interview on 08/20/21 at 11:40 AM with Resident #6's physician revealed he expected the Nurse Practitioner to physically look at Resident #6's new skin condition on her buttock within 3-4 days of the new skin condition appearing. He stated it was concerning to him on 08/15/21 of Resident #6 complaining of skin condition painful to the touch. He stated the Nurse Practitioner should have come and looked at Resident #6's skin on the 08/17/21 or 08/18/21 since it had gotten worse according to nurse documentation and she continued to give verbal orders to facility nurses starting with [MEDICATION(S)] 150 mg on 08/12/21 and 08/14/21. He stated according to his documentation the last progress note from the nurse practitioner for Resident #6 was on 07/26/21 and there was no documentation from the nurse practitioner about Resident #6's skin condition. He stated he was not notified by the Nurse Practitioner or the facility about Resident #6's rash on her buttocks or being sent to the hospital on 08/19/21. He stated he expected the nurse or the facility administration to contact him if Nurse Practitioner had not seen Resident #6's skin condition and the skin condition getting worse. Interview on 08/20/21 at 12:20 PM with Interim DON revealed she was not aware Nurse Practitioner had not physically looked at Resident #6's skin condition. She stated she expected if the current treatment was not working for Resident #6's skin condition and was getting worse the Nurse Practitioner should have come in to look at it or did a telehealth appointment with the nurse and Resident #6. She stated if she had been aware of Nurse Practitioner not seeing Resident #6's skin condition she would have gotten hold of Resident #6's physician to inform him. She stated the charge nurse should have informed her of Resident #6's rash getting worse and nurse practitioner only giving verbal orders for new treatments. She stated the Administrator talked to Resident #6 on 08/19/21 in the evening and finally agreed to go to the hospital due to a change in condition. Review of the facility's policy Skin Management revised July 2017 reflected Residents receive care to aide in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. Review of facility's policy Changes in Resident Condition revised February 2017 reflected the nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent avoidable accidents for 1 of 8 residents reviewed for accidents. (Resident #3) CNA A did not utilize a mechanical lift as directed in the resident's care plan while transferring Resident #3 resulting in the resident sustaining a [MEDICAL CONDITION] (a break in the upper arm near shoulder). Actual harm was determined to exist 10/10/2018 until 10/11/2018. 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 investigation. This failure affected one resident and could place other residents who require assistance with transfers at risk of avoidable accidents. Findings include: Review of Resident #3's Face Sheet reflected a [AGE] year-old female with an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] reflected Resident #3 had a Brief Summary Review for Mental Status score of 10 which indicated moderately impaired cognition. Resident #3 required extensive to total assistance with all activities of daily living. The MDS further reflected Resident #3 required assistance of two persons for transfers. Review of the quarterly MDS dated [DATE] reflected Resident #3 required extensive to total assistance with all activies of daily living. The MDS further reflected Resident #3 required assistance of two persons for transfers. Review of Resident #3's care plan with a revision date of 11/05/2018 reflected she was unable to transfer and required a mechanical lift for all transfers. Review of the emergency department provider notes dated 10/10/2018 reflected Resident #3 presented with a left shoulder problem. Resident #3 stated someone was trying to lift her by looping their arms under hers and she heard 3 cracks. Further review reflected Resident #3 was diagnosed with [REDACTED]. Resident #3 was not a surgical candidate. During an interview on 01/28/2019 at 12:59 p.m., Resident #3 stated she broke her shoulder during a transfer. Resident #3 stated she was not transferred using a mechanical lift when the injury happened. Resident #3 stated it took a while for her shoulder to heal and it has been very painful. Resident #3 stated she has to rely completely on staff to move her. Review of CNA A's typed statement dated 10/11/18 read in part, I felt I could transfer her by myself. I grabbed a gait belt from another room and put that on her. I used that to transfer her to and from bed. When I lifted with gait belt it slid up and my forearms were high up on her side about breast. Her arm was over the top of my arm. During the transfer I heard her shoulder pop. I laid her down and called the medication aide to get the nurse to come assess. CNA A further stated she did not know how to transfer Resident #3, but was aware of where to find information on resident care needs at the facility. Review of the provider investigation report dated 10/17/18 reflected CNA A thought she could lift (Resident #3) because she was so small. During the transfer the gait belt slid upward and they both heard several loud pops. The provider investigation report read in part, She (CNA A) made a very bad decision on how to transfer her (Resident #3). She had opportunities to ask for information or look up information and didn't. The report indicated the findings were confirmed and CNA A was terminated. It was determined the above failures caused actual harm past non-compliance to Resident #3 from 10/10/2018 until 10/11/2018. The facility took the following actions to correct the non-compliance on 10/11/2018. 1. On 10/11/2018 all nursing staff were in-serviced on proper resident transfers with a hydraulic lift. 2. On 10/11/2018 all nursing staff were in-serviced on how to conduct safe transfers. 3. On 10/11/2018 all nursing staff were in-serviced on abuse and neglect policies and procedures. 4. CNA A did not return to work at the facility and employment was terminated. During an interview on 01/28/2019 at 2:00 p.m., the Administrator stated he typically believed in re-educating staff, but felt CNA A demonstrated through her actions and her responses to his questions she had the knowledge of where to find the information regarding Resident #3, but chose not to. During an interview on 01/28/2019 at 12:51 p.m., CNA B stated Resident #3 required a 2 person transfer with a mechanical lift. CNA B stated information on the care needs of residents can be found at the nurse's station. During an interview on 01/28/2019 at 1:30 p.m., CNA C stated Resident #3 must be transferred using the mechanical lift. CNA C stated she checks resident's care needs on the computer at the nurse's station if she is unfamiliar with them. The investigator interviewed four CNAs, two LVNs, and two RNs on 01/28/2019 and all were knowledgeable of abuse/neglect policies/procedures, proper resident transfer techniques and of reviewing resident's care plans prior to performing transfers on residents with whom they are unfamiliar. During an observation on 01/28/2019 at 1:24 p.m., CNA B and CNA C transferred Resident #3 from her broda (tilt) chair to her bed using a mechanical lift in accordance with the care plan. The transfer was performed correctly and without injury. During an interview on 01/28/2019 at 12:55 p.m., the ADON stated the facility has implemented weekly in-services regarding resident care needs. The ADON stated physical therapy will also do further training on residents they are currently working with. The ADON stated the nurse's perform skill checks on the CNAs and full reviews are completed every 3 to 4 months. Review of facility in-service documentation reflected on 10/11/2018 all staff attended in-services on Understanding Abuse and Neglect and the Point of Care system used to document resident care needs. During an interview on 01/28/2019 at 3:00 p.m., the DON stated she expected the CNAs and nurses to perform transfers by policy and in accordance with the resident care plans.

Based on observation, interview and record review, the facility failed to ensure 2 of 16 residents (Resident #'s 11 and 16) 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. A. The facility failed to provide interventions to prevent further injury to Resident #16's right heel after a Deep Tissue Injury was discovered. B. Resident #11 was observed on 12/28/16 to have one unidentified pressure ulcer to his left lateral posterior proximal thigh, and one pressure ulcer to his right upper posterior buttocks that had been identified the previous day (12/27/16), but the physician had not been notified and no treatment orders were in place to promote healing or prevent infection. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/30/16. While the IJ was lowered on 12/30/16, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This deficient practice placed 14 other residents at risk for not receiving timely care and treatment of [REDACTED]. Findings include: A. Review of the facility Admission Record for Resident #16 revealed he was admitted to the facility 5/01/13 and readmitted on [DATE]. He was an [AGE] year old male resident with [DIAGNOSES REDACTED]. Review of the Care Plans for Resident #16 reflected the following: Resident has Potential/Actual skin Issues 10/21/16; DTI to Right Lateral Heel Interventions included: Notify Physician of changes in wound or emerging wounds;dated 10/13/16 Observe wound healing; dated 11/06/16 Provide wound care/preventative skin care per order; dated 11/6/16 Turn and reposition frequently to decrease pressure; dated 11/6/16 On 12/27/16 at 11:45 AM, Resident #16 was observed in the dining room sitting in a wheelchair. He had slipper socks on his feet and was using his right foot to propel himself around. On 12/28/16 at 10:00 AM, Resident #16 was observed in the main hallway sitting in a wheelchair. He was using his right foot to propel himself in his chair. He was wearing slipper socks on his feet. On 12/29/16, during selection for review for the extended survey, Resident #16 was chosen from a facility provided list of residents identified with pressure ulcers. Observations on 12/29/16 at 4:45 PM revealed Resident #16 had wounds on the top of three toes and on the heel of his right foot. These wounds were observed after Resident #16 scooted himself up in the bed using his right heel. CNA F had completed wound care and was waiting to cover the resident when he asked the surveyor to look at his toes and heel. He removed his non-slip socks with the toes of his left foot. The three toes on his right foot were reddened and the toe next to the right big toe had a scab on the wound. The heel on his right foot had a black area the approximate size of a nickel. CNA F helped replace Resident #16's socks. No pillows or offloading devices for Resident #16's foot were seen in his room. During an interview on 12/29/16 at 4:45 PM, Resident #16 stated that his toes and heel hurt. On 12/29/16 at 10:30 AM, Resident #16 was observed lying in his bed resting. No offloading devices for his foot were noted. There were no extra pillows or positioning devices in the room. The charge nurse stated the treatment nurse had already treated the Resident's heel with Skin Prep (liquid film-forming barrier). The resident stated that the areas on his foot hurt when touched. RN N removed the resident's sock to reveal his right foot. His three middle toes had crusted reddened areas on top. There was no padding or protection other than a slipper sock on the right foot. The charge nurse, RN N, stated they treat the area with the Skin Prep daily. (SKIN-PREP is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films. SKIN-PREP can also be used to prepare skin attachment sites for drainage tubes, external catheters, surrounding ostomy sites and adhesive dressings). During an interview on 12/30/16 at 1:00 PM, the Medical Director for Hospice stated that he had spoken with the Hospice Case Manager and he was unaware Resident #16's wound had progressed to necrotic tissue. Review of the Weekly Pressure Ulcer Records dated 10/21/16 through 12/27/16 revealed the facility had not changed the treatment or notified the primary care physician when the area to the heel changed in character and on 11/4/16 was noted to be No longer soft and boggy. There was no documentation to show this change in wound character was reported to the physician. A physician order [REDACTED]. During an interview on 12/29/16 at 5:00 PM, the Director of Nurses (DON) stated that the wound on Resident #16's heel was a callous (a hard and thickened area) and they were treating it with Skin Prep, She stated the orders were from Hospice and the DON did not identify any interventions other than Skin Prep for the care of Resident #16's wound. Review of a Weekly Pressure Ulcer Record for Resident #16, Date of Onset: 10/21/16. Site /Location: Right lateral heel. The area was staged as a Deep Tissue Injury (DTI), 3.9 cm x 2cm (centimeter). The wound bed was described as black with the surrounding skin color normal for skin. Review of a physician order [REDACTED]. On 10/22/16, a Palliative Care Form was initiated. Under the sub heading of Skin breakdown and/or pressure sores was the following statement: The facility/agency will remain consistent with palliative care, plan and implement measures that will preserve as much skin integrity as possible. On 10/27/16, the Weekly Pressure Ulcer Report reflected Wound staged as DTI at 2.8 cm x 1.7 cm with a black wound bed. LVN A documented the DTI to Rt. Lateral Heel. is purple black and red at this time. She documented pillows for offloading. (use of pillow to lift feet from the bed surface.) Review of the Weekly Pressure Ulcer Record dated 11/4/16 reflected a measurement of 1.5cm x 1.5cm with a black wound bed. Under the section for notes documentation revealed the observation the wound was No longer soft and boggy. No documentation was provided to show this change in wound character was reported to the physician. as had been ordered on [DATE]. There were no changes in treatment initiated at that time. Review of the Weekly Pressure Ulcer Records dated 11/28/16, 11/25/16, 12/2/16 and 12/6/16 reflected a description of the wound as a DTI of the right lateral heel with a black wound bed (necrotic tissue) and black wound edges. The measurements remained 1.5 cm x 1.5 cm during this time. No interventions were initiated to prevent further damage. There was no acknowledgement of the areas to the three middle toes of the right foot in any of the weekly pressure assessments and no recommendations for treatment. There was no documentation provided as to when these areas occurred and what had caused them. On 12/27/16, the Weekly Pressure Ulcer Record reflected the area continued to be described as a DTI of the right lateral heel with black wound bed. Review of the website for the National Pressure Ulcer Advisory Panel reflected the following: A deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration. The facility provided the following information from Lippincott Procedures- Pressure injury management, long-term care: Deep Tissue Pressure Injury was defined as a deep tissue injury characterized by a intact or non-intact skin with a localized area of persistent deep red, purple, or maroon discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. This injury results from intense or prolonged pressure and shear forces at the bone-muscle interface. If Necrotic, subcutaneous, or granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or stage 4) On 12/30/16, the facility provided a copy of a document titled Clinically Unavoidable Skin Breakdown for Resident #16. It stated that a resident who has two or more of the following conditions should be evaluated for unavoidable skin breakdown. Diabetes and CKD Stage V ([MEDICAL CONDITION]) were noted. The following areas were left blank: Lab values, Interventions, Pressure Relief, Mobility, and Nutrition. DTI was indicated as a symptom. The skin care included Skin Prep. Vitamins, Decub-a-vite (multivitamin with minerals), were ordered. No other documentation regarding the DTI as being unavoidable was provided either in Progress Notes or skin assessments. There was no care plan defining the wound as unavoidable or other interventions that could prevent further breakdown and/or injury. Review of four Hospice Interdisciplinary Team conference notes dated 11/04/16, 11/18/16, and 12/16/16 reflected no identified skin impairment or pressure wound present. There were no interventions noted regarding skin care on these meetings On 12/29/16 at 4:15 PM, the Hospice DON (Director of Nurses) stated the case manager had been to the facility on [DATE]. She reported the wound to the right heel as a dry scab. They were continuing the treatment of [REDACTED]. On 12/29/16 at 6:30 PM, the Wound Care Consultant Physician stated in interview he had not seen Resident #16. He further stated the facility usually will consult him when a wound is staged at a III or IV. He stated, They use their own protocols on a Stage I or II. On 12/30/16 at 8:30 AM, the facility DON stated after the surveyors left on 12/29/16, the facility had asked the Wound Care Consultant Physician to assess the right heel of Resident # 16. She stated he had debrided the area. (Debridement is the process of removing non-living tissue from pressure ulcers, burns, and other wounds). On 12/30/16 the facility provided the Wound Care Specialist Initial Evaluation documentation dated 12/29/16. The description of the wound of the right, posterior, lateral heel was as follows: Exudate: Moderate Serous, Thick Adherent Devitalized Necrotic Tissue: 100%. The wound was debrided via surgical excision and muscle removed along with necrotic tissue. A treatment was ordered along with the recommendation to float heels in bed, off-load wound, reposition per facility protocol. B. Review of Resident #11's Admission Record dated 12/29/16 revealed a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #11 requires extensive 2 person assistance with bed mobility. He is incontinent of bowels and has an indwelling urinary catheter. Resident #11 was admitted with four Stage 3 pressure ulcers and one Unstageable Pressure Ulcer. Review of Resident #11's Care Plan initiated on 12/15/16 and revised on 12/29/16 revealed that Resident #11 has pressure injuries related to immobility and bowel incontinence. The following interventions were initiated 12/15/16: 1) Administer treatments as ordered and observe for effectiveness. 2) Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observation on 12/28/16 at 9:30 AM, revealed LVN's A and B turning Resident #11 to his left side for wound care to his right posterior buttock. An undated dressing was loosely covering a wound to his right posterior buttocks. Open pressure ulcers were also observed to Resident #11's right upper proximal buttocks and to the left lateral posterior proximal thigh, previously unidentified by the facility. There were no dressings covering the wounds to Resident #11's right upper proximal buttocks or left lateral posterior proximal thigh. The Wound Vac was not in place to the wound on the right posterior buttock per physician's orders [REDACTED].#11's right posterior buttock wound, but had to stop wound care to medicate Resident #11 for pain following surveyor intervention. Wound care was resumed at 11:45 AM, at which time the newly identified pressure ulcers were measured. The ulcer to Resident #11's right upper proximal buttocks measured 0.8 centimeters (cm) x 1.2cm. The ulcer to Resident #11's left lateral posterior proximal thigh measured 3.7cm x 0.3cm. During interview on 12/28/16 at 9:35 AM, LVN A stated that she was not aware of the wounds to Resident #11's right upper proximal buttock or left lateral posterior thigh, but would notify Resident #11's doctor to obtain wound care orders. LVN A stated, The nurses should be placing their eyes on the residents every shift. During interview on 12/28/16 at 9:40 AM, LVN B stated, I saw the open area to his right upper buttock yesterday. I did not notify the doctor of his wound, because I was going to have the wound care doctor look at it when he came today. I did not see the open area to his thigh. During interview on 12/29/16 at 12:30 PM, the Director of Nurses (DON) stated, Two to 3 weeks ago, I put 2 skin (treatment) nurses on the floor, because I wanted more focus on the wounds (pressure areas). The skin nurses are responsible for providing the wound care and performing the skin assessments. If the primary nurse identifies a new area, she can obtain an order from the doctor for wound care and communicate with the skin nurses. I have told the aides if they identify new areas to tell the nurse. During an interview on 12/29/16 at 5:45 PM, the Wound Care Consultant Physician stated that he has seen Resident #11, but was unaware of any new pressure areas. He stated that the facility would notify a resident's primary care physician for a wound staged at a I or II and should use their current skin protocol. Review of Resident #11's Weekly Pressure Ulcer Record dated 12/27/16 revealed an existing pressure ulcer ton the right (posterior) buttock he resident was admitted with on 11/30/16, measuring 5cm x 9cm x 3cm. There were no other pressure ulcers identified on the pressure ulcer record. Review of Resident #11's Wound Care Specialist Evaluation dated 12/21/16 revealed an Unstageable wound (due to necrosis) of the right posterior buttock measuring 4cm x 4cm x 1.7cm. The Wound Care Specialist Physician identified a Stage 3 wound to the left posterior buttock, a Stage 3 wound to the right posterior thigh and a Stage 3 wound to the medial sacrum which were all resolved on 12/21/16. Review of Resident #11's Wound Care Specialist Evaluation dated 12/29/16 revealed the following: History of Present Illness (HPI) Statement: Resident evaluated today and presents with a Stage 2 pressure wound of the right, proximal, lateral buttock of at least 7 days duration. There is moderate serous exudate. (drainage) Stage 2 Pressure Wound of the right proximal, lateral buttock measures 0.6cm x1cm x 0.1cm Shear wound of the left posterior lateral thigh measures 6.5cm x 0.2cm x 0.1cm Duration: >7 days Etiology:Shear Review of Resident #11's Order Summary Report for 12/1/16-12/31/16 dated 12/28/16 at 9:23 AM, revealed an order to Clean the right posterior buttocks with Normal Saline, apply [MEDICATION NAME] 1% (a cream used to decrease odors) apply Collagen (used to promote wound healing), apply black [MEDICATION NAME] to fit wound bed and attach Wound Vac bridged to anterior thigh. Wound Vac to function at 125mmHG contionous and to be changed on Monday, Wednesday and Friday evenings and as needed. There were no other wound care orders. Review of a current facility policy titled, Skin Management (revised August 2012) revealed the following: Overview: Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Stage II Pressure Ulcer Suggested Interventions: 1. Resident, family and attending physician are notified of development of a Stage II ulcer. 3. Care Plan and Assignment Sheet/Care Kardex are updated to reflect new problem and interventions. 5. Resident is added to 24 hour report. The facility Administrator was notified on 12/30/16 at 1:59 PM that an Immediate Jeoparty (IJ)situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 12/30/16 at 6:10 PM. The final Plan of Removal was accepted by the Survey team on 12/30/16 at 6:38 PM. Plan of Removal submitted by the facility: On December 30, 2016 at 2:06 PM Texas Department of Aging and Disability conducting annual survey notified the Administrator of Immediate Threat called relative to a wound on Resident #16. Resident #16 was admitted to Lake Shore Village May 1, 2013 with a [DIAGNOSES REDACTED]. On 10-21-16 a suspected deep tissue injury was identified to the right lateral heal (heel) measuring 2.8 x1.7. An order was obtained to cleans with normal saline, pat dry, apply skin prep daily. This order was carried out. On 12-27-16 the wound assessment showed the suspected deep tissue injury to measure 1.1 x 1.8. Skin prep was still treatment and wound was decreasing in size. On 12/29/16 Surveyor questioned the type of wound. Wound Care Consultant Physician assessed the wound and removed the necrotic tissue resulting in depth of 0.3 cm. Immediate action taken: On December 29, 2016 the following was conducted by the Corporate Nurse, DON; ADON; LVN, Unit Manager, LVN, Unit Manager, DON, LVN, Unit Manager, LVN - 100% skin assessments were initiated and completed December 30,2016 - In-services were initiated for all nurses including weekend and PRN regarding pain assessment and management and pressure injury management. (See attached) These will be completed December 30, 2016. Any nurse that has not received the in-service on December 30, 2016 will not work until the in- service has been done. - Wound Care Consultant Physician assessed all resident's with pressure injuries. On December 30, 2016 the following was conducted by the Corporate Nurse, DON; ADON; LVN, Unit Manager, LVN, Unit Manager; - In-service for all nurses including weekend and PRN regarding pressure injury prevention, understanding skin breakdown and recognizing and reporting change in resident's physical condition. Notifying unit managers, ADON, DON, and Administrator on any new skin issues with post test. (See attached) This will be completed December 30, 2016. Any nurse that has not received the in-service on December 30, 2016 will not work until the in-service has be done. - Referrals will be made to Physical therapy and Registered Dietitian for all pressure injuries. - All care plans will be reviewed and revised as indicated. Monitoring: - DON; LVN, ADON; LVN, Unit Manager, LVN, Unit Manager will review and observe all wound treatments every week for 4 weeks to ensure compliance. - QAPI committee will meet weekly for 4 weeks and then every other month until compliance is achieved. Committee will review findings from the review and observation of all wound treatments and make additional recommendations. Signed: Administrator Date: 12/30/16 The survey team monitored the current plan of removal as follows: Interviews were conducted with staff regarding the inservices conducted on 12/29/16-12/30/16. The inservice was titled When you Observe a New Skin Area. This included information from the Lippincott Procedure references on identification and treatments of pressure areas. On 12/30/16 at 8:45 PM, the Administrator was informed the IJ was lowered. However the facility remained out of compliance at a severity of actual harm that was not an Immediate Threat with a scope of a pattern due to the facility required time to monitor their Plan of Removal. The facility provided CMS form 672 dated 12/28/16 revealed 16 residents with pressure ulcers.

Based on observations, interviews, and record reviews the facility Administrator failed to provide oversight in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 2 of 16 residents identified with wounds. (Resident #11 and #16) A. The Director of Nurses (DON) failed to implement facility policies and procedures regarding pressure sore assessments, treatment, and following physician orders [REDACTED].>(1) Resident #16's Deep Tissue Injury did not receive timely and measurable interventions to prevent the wound from worsening. (2) A wound care nurse failed to report a new Stage II pressure ulcer for Resident #11. The wound care nurse removed Resident #11's wound vac without a physician's orders [REDACTED].>(3) A wound care nurse did not assess Resident #11 for pain and did not stop dressing wound when the resident expressed pain. B. The Administrator failed to oversee the Director of Nurses (DON) to ensure she was monitoring and training the nursing staff on completing accurate and timely nursing assessments, performing wound care, and following Physician orders. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/30/16. While the IJ was lowered on 12/30/16, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This deficient practice affected the timely care and treatment of [REDACTED].#11 and #16 and could affect the other 14 residents by not providing therapeutic and timely treatments for wounds, and cause pain to residents during wound care. Findings include: A. (1) A. Review of the facility Admission Record for Resident #16 revealed he was admitted to the facility 5/01/13 and readmitted on [DATE]. He was an [AGE] year old male resident with [DIAGNOSES REDACTED]. Review of the Care Plans for Resident #16 reflected the following: Resident has Potential/Actual skin Issues 10/21/16; DTI to Right Lateral Heel Interventions included: Notify Physician of changes in wound or emerging wounds; dated 10/13/16 Observe wound healing; dated 11/06/16 Provide wound care/preventative skin care per order; dated 11/6/16 Turn and reposition frequently to decrease pressure; dated 11/6/16 On 12/27/16 at 11:45 AM, Resident #16 was observed in the dining room sitting in a wheelchair. He had slipper socks on his feet and was using his right foot to propel himself around. On 12/28/16 at 10:00 AM, Resident #16 was observed in the main hallway sitting in a wheelchair. He was using his right foot to propel himself in his chair. He was wearing slipper socks on his feet. On 12/29/16, during selection for review for the extended survey, Resident #16 was chosen from a facility provided list of residents identified with pressure ulcers. Observations on 12/29/16 at 4:45 PM revealed Resident #16 had wounds on the top of three toes and on the heel of his right foot. These wounds were observed after Resident #16 scooted himself up in the bed using his right heel. CNA F had completed wound care and was waiting to cover the resident when he asked the surveyor to look at his toes and heel. He removed his non-slip socks with the toes of his left foot. The three toes on his right foot were reddened and the toe next to the right big toe had a scab on the wound. The heel on his right foot had a black area the approximate size of a nickel. CNA F helped replace Resident #16's socks. No pillows or offloading devices for Resident #16's foot were seen in his room. During an interview on 12/29/16 at 4:45 PM, Resident #16 stated that his toes and heel hurt. On 12/29/16 at 10:30 AM, Resident #16 was observed lying in his bed resting. No offloading devices for his foot were noted. There were no extra pillows or positioning devices in the room. The charge nurse stated the treatment nurse had already treated the Resident's heel with Skin Prep (liquid film-forming barrier). The resident stated that the areas on his foot hurt when touched. RN N removed the resident's sock to reveal his right foot. His three middle toes had crusted reddened areas on top. There was no padding or protection other than a slipper sock on the right foot. The charge nurse, RN N, stated they treat the area with the Skin Prep daily. (SKIN-PREP is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films. SKIN-PREP can also be used to prepare skin attachment sites for drainage tubes, external catheters, surrounding ostomy sites and adhesive dressings). During an interview on 12/30/16 at 1:00 PM, the Medical Director for Hospice stated that he had spoken with the Hospice Case Manager and he was unaware Resident #16's wound had progressed to necrotic tissue. Review of the Weekly Pressure Ulcer Records dated 10/21/16 through 12/27/16 revealed the facility had not changed the treatment or notified the primary care physician when the area to the heel changed in character and on 11/4/16 was noted to be No longer soft and boggy. There was no documentation to show this change in wound character was reported to the physician. A physician order [REDACTED]. During an interview on 12/29/16 at 5:00 PM, the Director of Nurses (DON) stated that the wound on Resident #16's heel was a callous (a hard and thickened area) and they were treating it with Skin Prep, She stated the orders were from Hospice and the DON did not identify any interventions other than Skin Prep for the care of Resident #16's wound. Review of a Weekly Pressure Ulcer Record for Resident #16, Date of Onset: 10/21/16. Site /Location: Right lateral heel. The area was staged as a Deep Tissue Injury (DTI), 3.9 cm x 2cm (centimeter). The wound bed was described as black with the surrounding skin color normal for skin. Review of a physician order [REDACTED]. On 10/22/16, a Palliative Care Form was initiated. Under the sub heading of Skin breakdown and/or pressure sores was the following statement: The facility/agency will remain consistent with palliative care, plan and implement measures that will preserve as much skin integrity as possible. On 10/27/16, the Weekly Pressure Ulcer Report reflected Wound staged as DTI at 2.8 cm x 1.7 cm with a black wound bed. LVN A documented the DTI to Rt. Lateral Heel. is purple black and red at this time. She documented pillows for offloading. (use of pillow to lift feet from the bed surface.) Review of the Weekly Pressure Ulcer Record dated 11/4/16 reflected a measurement of 1.5cm x 1.5cm with a black wound bed. Under the section for notes documentation revealed the observation the wound was No longer soft and boggy. No documentation was provided to show this change in wound character was reported to the physician. as had been ordered on [DATE]. There were no changes in treatment initiated at that time. Review of the Weekly Pressure Ulcer Records dated 11/28/16, 11/25/16, 12/2/16 and 12/6/16 reflected a description of the wound as a DTI of the right lateral heel with a black wound bed (necrotic tissue) and black wound edges. The measurements remained 1.5 cm x 1.5 cm during this time. No interventions were initiated to prevent further damage. There was no acknowledgement of the areas to the three middle toes of the right foot in any of the weekly pressure assessments and no recommendations for treatment. There was no documentation provided as to when these areas occurred and what had caused them. On 12/27/16, the Weekly Pressure Ulcer Record reflected the area continued to be described as a DTI of the right lateral heel with black wound bed. Review of the website for the National Pressure Ulcer Advisory Panel reflected the following: A deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration. The facility provided the following information from Lippincott Procedures- Pressure injury management, long-term care: Deep Tissue Pressure Injury was defined as a deep tissue injury characterized by an intact or non-intact skin with a localized area of persistent deep red, purple, or maroon discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. This injury results from intense or prolonged pressure and shear forces at the bone-muscle interface. If Necrotic, subcutaneous, or granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or stage 4) On 12/30/16, the facility provided a copy of a document titled Clinically Unavoidable Skin Breakdown for Resident #16. It stated that a resident who has two or more of the following conditions should be evaluated for unavoidable skin breakdown. Diabetes and CKD Stage V ([MEDICAL CONDITION]) were noted. The following areas were left blank: Lab values, Interventions, Pressure Relief, Mobility, and Nutrition. DTI was indicated as a symptom. The skin care included Skin Prep. Vitamins, Decub-a-vite (multivitamin with minerals), were ordered. No other documentation regarding the DTI as being unavoidable was provided either in Progress Notes or skin assessments. There was no care plan defining the wound as unavoidable or other interventions that could prevent further breakdown and/or injury. Review of four Hospice Interdisciplinary Team conference notes dated 11/04/16, 11/18/16, and 12/16/16 reflected no identified skin impairment or pressure wound present. There were no interventions noted regarding skin care on these meetings On 12/29/16 at 4:15 PM, the Hospice DON (Director of Nurses) stated the case manager had been to the facility on [DATE]. She reported the wound to the right heel as a dry scab. They were continuing the treatment of [REDACTED]. On 12/29/16 at 6:30 PM, the Wound Care Consultant Physician stated in interview he had not seen Resident #16. He further stated the facility usually will consult him when a wound is staged at a III or IV. He stated, They use their own protocols on a Stage I or II. On 12/30/16 at 8:30 AM, the facility DON stated after the surveyors left on 12/29/16, the facility had asked the Wound Care Consultant Physician to assess the right heel of Resident # 16. She stated he had debrided the area. (Debridement is the process of removing non-living tissue from pressure ulcers, burns, and other wounds). On 12/30/16 the facility provided the Wound Care Specialist Initial Evaluation documentation dated 12/29/16. The description of the wound of the right, posterior, lateral heel was as follows: Exudate: Moderate Serous, Thick Adherent Devitalized Necrotic Tissue: 100%. The wound was debrided via surgical excision and muscle removed along with necrotic tissue. A treatment was ordered along with the recommendation to float heels in bed, off-load wound, reposition per facility protocol. A (2). Review of Resident #11's Admission Record dated 12/29/16 revealed a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #11 requires extensive 2 person assistance with bed mobility. He is incontinent of bowels and has an indwelling urinary catheter. Resident #11 was admitted with four Stage 3 pressure ulcers and one Unstageable Pressure Ulcer. Review of Resident #11's Care Plan initiated on 12/15/16 and revised on 12/29/16 revealed that Resident #11 has pressure injuries related to immobility and bowel incontinence. The following interventions were initiated 12/15/16: 1) Administer treatments as ordered and observe for effectiveness. 2) Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observation on 12/28/16 at 9:30 AM, revealed LVN's A and B turning Resident #11 to his left side for wound care to his right posterior buttock. An undated dressing was loosely covering a wound to his right posterior buttocks. Open pressure ulcers were also observed to Resident #11's right upper proximal buttocks and to the left lateral posterior proximal thigh, previously unidentified by the facility. There were no dressings covering the wounds to Resident #11's right upper proximal buttocks or left lateral posterior proximal thigh. The Wound Vac was not in place to the wound on the right posterior buttock per physician's orders [REDACTED].#11's right posterior buttock wound, but had to stop wound care to medicate Resident #11 for pain following surveyor intervention. Wound care was resumed at 11:45 AM, at which time the newly identified pressure ulcers were measured. The ulcer to Resident #11's right upper proximal buttocks measured 0.8 centimeters (cm) x 1.2cm. The ulcer to Resident #11's left lateral posterior proximal thigh measured 3.7cm x 0.3cm. During interview on 12/28/16 at 9:35 AM, LVN A stated that she was not aware of the wounds to Resident #11's right upper proximal buttock or left lateral posterior thigh, but would notify Resident #11's doctor to obtain wound care orders. LVN A stated, The nurses should be placing their eyes on the residents every shift. During interview on 12/28/16 at 9:40 AM, LVN B stated, I saw the open area to his right upper buttock yesterday. I did not notify the doctor of his wound, because I was going to have the wound care doctor look at it when he came today. I did not see the open area to his thigh. During interview on 12/29/16 at 12:30 PM, the Director of Nurses (DON) stated, Two to 3 weeks ago, I put 2 skin (treatment) nurses on the floor, because I wanted more focus on the wounds (pressure areas). The skin nurses are responsible for providing the wound care and performing the skin assessments. If the primary nurse identifies a new area, she can obtain an order from the doctor for wound care and communicate with the skin nurses. I have told the aides if they identify new areas to tell the nurse. During an interview on 12/29/16 at 5:45 PM, the Wound Care Consultant Physician stated that he has seen Resident #11, but was unaware of any new pressure areas. He stated that the facility would notify a resident's primary care physician for a wound staged at a I or II and should use their current skin protocol. Review of Resident #11's Weekly Pressure Ulcer Record dated 12/27/16 revealed an existing pressure ulcer ton the right (posterior) buttock he resident was admitted with on 11/30/16, measuring 5cm x 9cm x 3cm. There were no other pressure ulcers identified on the pressure ulcer record. Review of Resident #11's Wound Care Specialist Evaluation dated 12/21/16 revealed an Unstageable wound (due to necrosis) of the right posterior buttock measuring 4cm x 4cm x 1.7cm. The Wound Care Specialist Physician identified a Stage 3 wound to the left posterior buttock, a Stage 3 wound to the right posterior thigh and a Stage 3 wound to the medial sacrum which were all resolved on 12/21/16. Review of Resident #11's Wound Care Specialist Evaluation dated 12/29/16 revealed the following: History of Present Illness (HPI) Statement: Resident evaluated today and presents with a Stage 2 pressure wound of the right, proximal, lateral buttock of at least 7 days duration. There is moderate serous exudate. (drainage) Stage 2 Pressure Wound of the right proximal, lateral buttock measures 0.6cm x1cm x 0.1cm Shear wound of the left posterior lateral thigh measures 6.5cm x 0.2cm x 0.1cm Duration: >7 days Etiology: Shear Review of Resident #11's Order Summary Report for 12/1/16-12/31/16 dated 12/28/16 at 9:23 AM, revealed an order to Clean the right posterior buttocks with Normal Saline, apply [MEDICATION NAME] 1% (a cream used to decrease odors) apply Collagen (used to promote wound healing), apply black [MEDICATION NAME] to fit wound bed and attach Wound Vac bridged to anterior thigh. Wound Vac to function at 125mmHG continuous and to be changed on Monday, Wednesday and Friday evenings and as needed. There were no other wound care orders. Review of a current facility policy titled, Skin Management (revised August 2012) revealed the following: Overview: Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Stage II Pressure Ulcer Suggested Interventions: 1. Resident, family and attending physician are notified of development of a Stage II ulcer. 3. Care Plan and Assignment Sheet/Care Kardex are updated to reflect new problem and interventions. 5. Resident is added to 24 hour report. A. (3) Review of Resident #11's facility Admission Record dated 12/29/16 revealed a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #11 requires extensive 2 person assistance with bed mobility. He is incontinent of bowels and has an indwelling urinary catheter. Resident #11 was admitted with four Stage 3 pressure ulcers and one Unstageable Pressure Ulcer. Review of Resident #11's Care Plan initiated on 12/15/16 and revised on 12/29/16 revealed the following: 1. Resident #11 has pressure injuries related to immobility and bowel incontinence. The following interventions were initiated 12/15/16: Administer treatments as ordered and observe for effectiveness. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Treat pain as ordered prior to treatment, turning etc. to ensure the resident's comfort. 2. Resident #11 has chronic pain issues related to pressure injuries and impaired mobility. (Initiated 12/14/16) Interventions: Administer pain medication as ordered. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Observation on 12/28/16 at 9:30 AM, revealed LVN A gathering supplies to provide wound care to an Unstageable pressure ulcer to Resident #11's right posterior buttock. LVN A and LVN B entered the room, prepared the supplies and turned Resident #11 to his left side for wound care. LVN A and LVN B did not assess Resident #11's pain prior to beginning wound care. An undated dressing was loosely covering a wound to his right posterior buttocks. Open pressure ulcers were also observed to Resident #11's right upper proximal buttocks and left lateral posterior proximal thigh, which was previously unidentified by the facility. There were no dressings covering the wounds to Resident #11's right upper proximal buttocks or left lateral posterior proximal thigh. The Wound Vac was not in place to the wound on the right posterior buttock per physician's orders [REDACTED].#11's buttocks. Resident #11 grimaced and hollered oh several times clinching his buttocks while LVN A was removing the loose dressing. LVN A and LVN B asked Resident #11 if he was ok and he said no. LVN A then began using Normal Saline to moisten the black [MEDICATION NAME] on the wound bed to loosen the dressing for removal. Each time LVN A used the Normal Saline and attempted to remove the foam dressing, Resident #11 grimaced, hollered oh and clinched his buttocks when the wound was touched. Despite Resident #11's grimacing, hollering oh and clinching his buttocks when the wound was touched, LVN A and LVN B did not ask the resident if he was in pain or if he needed pain medication. Surveyor then intervened and asked LVN A if Resident #11 had been medicated for pain prior to wound care at which time LVN A stopped the wound care, and stated she would give the resident some pain medication. Observation on 12/28/16 at 11:45 AM, revealed LVN A gathering supplies to resume wound care to Resident #11's Unstageable pressure ulcer. LVN A and LVN B entered Resident #11's room and prepared the supplies for wound care. LVN A and LVN B did not re-assess Resident #11's pain prior to beginning wound care. LVN A and LVN B turned Resident #11 to his left side. LVN A then provided wound care to the newly identified area to his right posterior buttocks without complaints of pain. Without assessing Resident #11's pain, LVN B began moistening the black [MEDICATION NAME] dressing with Normal Saline to loosen the foam dressing. Resident #11 hollered oh and clinched his buttocks as she removed the [MEDICATION NAME] dressing. She then began cleaning the wound with Normal Saline and a 4x4 dressing and Resident #11 stated, It hurts. LVN A then applied a new [MEDICATION NAME] dressing to the wound, removed it and applied [MEDICATION NAME] (a cream applied to the wound bed to control odors) to the wound bed. LVN B told LVN A several times during the wound care, He is still saying it hurts. LVN A continued to provide the treatment to Resident #11's Unstageable pressure area despite Resident #11 continuing to grimace, say oh it hurts and clinching his buttocks whenever the wound was touched. When LVN A was finished with wound care, she stated that she would talk to the doctor and see if she could get an order for [REDACTED]. During an interview on 12/29/16 at 12:30 PM, the Director of Nurses (DON) stated that she would expect the nurses to assess the resident's pain prior to wound care and stop the treatment if a resident complains of pain. The DON stated, I talked to Resident #11 this morning and he said that he does experience discomfort and pain with treatments (wound care). I talked to the Wound Care Consultant Physician this morning who is discontinuing the Wound Vac. I also spoke with the Medical Director who has ordered routine [MEDICATION NAME] (a liquid pain medication containing [MEDICATION NAME]) 30 minutes prior to wound care. Review of Resident #11's Order Summary Report for December 1 through December 31, 2016 revealed the following orders: 1. [MEDICATION NAME] (a mild pain reliever) 50mg 1 tablet by mouth (PO) at bedtime (hs) for pain. 2. [MEDICATION NAME] 50mg 1 tablet PO every 6 hours as needed (PRN) for pain. 3.Clean the right posterior buttocks with Normal Saline, apply [MEDICATION NAME] 1% (a cream used to decrease odors) apply Collagen (used to promote wound healing), apply black [MEDICATION NAME] to fit wound bed and attach Wound Vac bridged to anterior thigh. Wound Vac to function at 125mmHG continuous and to be changed on Monday, Wednesday and Friday evenings and as needed. There were no other wound care orders. Review of Resident #11's Medication Administration Record [REDACTED]. Resident #11 had not received any pain medication on 12/28/16 prior to wound care. Review of a current facility policy titled, Skin Management (revised August 2012) revealed the following: Overview: Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Stage II Pressure Ulcer Suggested Interventions: 1. Resident, family and attending physician are notified of development of a Stage II ulcer. 3. Care Plan and Assignment Sheet/Care Kardex are updated to reflect new problem and interventions. 5. Resident is added to 24 hour report. Review of a current facility policy titled, Pain Management (revised August 2012) revealed the following: 10. The staff will implement the Care Plan, monitor the resident and administer B. During an interview on 12/29/16 at 10:10 AM in reference to the wound care for Resident #11, the Administrator stated, Ok, I will get that fixed. The facility Administrator was notified on 12/30/16 at 1:59 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 12/30/16 at 6:10 PM. The final Plan of Removal was accepted by the Survey team on 12/30/16 at 6:38 PM. Plan of Removal submitted by the facility: On December 30, 2016 at 2:06 PM Texas Department of Aging and Disability conducting annual survey notified the Administrator of Immediate Jeopardy called relative to a wound on Resident #16. Resident #16 was admitted to Lake Shore Village May 1, 2013 with a [DIAGNOSES REDACTED]. On 10-21-16 a suspected deep tissue injury was identified to the right lateral heal (heel) measuring 2.8 x1.7. An order was obtained to cleans with normal saline, pat dry, apply skin prep daily. This order was carried out. On 12-27-16 the wound assessment showed the suspected deep tissue injury to measure 1.1 x 1.8. Skin prep was still treatment and wound was decreasing in size. On 12/29/16 Surveyor questioned the type of wound. Wound Care Consultant Physician assessed the wound and removed the necrotic tissue resulting in depth of 0.3 cm. Immediate action taken: On December 29, 2016 the following was conducted by the Corporate Nurse, DON; ADON; LVN, Unit Manager, LVN, Unit Manager, DON, LVN, Unit Manager, LVN - 100% skin assessments were initiated and completed December 30,2016 - In-services were initiated for all nurses including weekend and PRN regarding pain assessment and management and pressure injury management. (See attached) These will be completed December 30, 2016. Any nurse that has not received the in-service on December 30, 2016 will not work until the in- service has been done. - Wound Care Consultant Physician assessed all resident's with pressure injuries. On December 30, 2016 the following was conducted by the Corporate Nurse, DON; ADON; LVN, Unit Manager, LVN, Unit Manager; - In-service for all nurses including weekend and PRN regarding pressure injury prevention, understanding skin breakdown and recognizing and reporting change in resident's physical condition. Notifying unit managers, ADON, DON, and Administrator on any new skin issues with post test. (See attached) This will be completed December 30, 2016. Any nurse that has not received the in-service on December 30, 2016 will not work until the in-service has be done. - Referrals will be made to Physical therapy and Registered Dietitian for all pressure injuries. - All care plans will be reviewed and revised as indicated. Monitoring: - DON; LVN, ADON; LVN, Unit Manager, LVN, Unit Manager will review and observe all wound treatments every week for 4 weeks to ensure compliance. - QAPI committee will meet weekly for 4 weeks and then every other month until compliance is achieved. Committee will review findings from the review and observation of all wound treatments and make additional recommendations. Signed: Administrator Date: 12/30/16 The survey team monitored the current plan of removal as follows: Interviews were conducted with staff regarding the inservices conducted on 12/29/16-12/30/16. The inservice was titled When you Observe a New Skin Area. This included information from the Lippincott Procedure references on identification and treatments of pressure areas. On 12/30/16 at 8:45 PM, the Administrator was informed the IJ was lowered. However the facility remained out of compliance at a severity of actual harm that was not an Immediate Jeopardy with a scope of a pattern due to the facility required time to monitor their Plan of Removal. The facility provided CMS form 672 dated 12/28/16 revealed 16 residents with pressure ulcers, 11 of which had pressure ulcers on admission.

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents, (Resident #'s 2, 11, and 18) and failed to have systematic procedures in place for the care of Dementia (Cognitively Impaired) residents for 58 residents who had a [DIAGNOSES REDACTED]. A. The facility failed to assess Resident # 11's pain prior to wound care, and surveyor had to intervene for resident to be medicated prior to proceeding with the care. When wound care resumed a second time after being medicated, Licensed Vocational Nurse (LVN) A never re-assessed Resident #11's pain prior to starting the wound care. LVN A and LVN B continued providing wound care a second time to Resident #11 despite his verbal and non-verbal signs of pain. B. Resident #2 was not assessed for pain due to a headache until the surveyor intervened and requested the nurse check the resident's blood pressure. Registered Nurse (RN) N did not place the blood pressure cuff on the forearm correctly when the surveyor requested the staff take the resident's blood pressure. C. Resident #18's Tylenol #3 (Tylenol with [MEDICATION NAME] - a narcotic medication for pain management) was not ordered from the Pharmacy. D. The facility did not have policies or procedures for the systematic person-centered care of 58 residents diagnosed with [REDACTED]. This deficient practice affected 3 Residents that verbalized pain and could potentially affect 6 other residents by not receiving timely pain management and could potentially affect 58 Dementia residents by causing a loss of self esteem and decreased quality of life. Findings Include: A. Review of Resident #11's facility Admission Record dated [DATE] revealed a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #11 requires extensive 2 person assistance with bed mobility. He is incontinent of bowels and has an indwelling urinary catheter. Resident #11 was admitted with four Stage 3 pressure ulcers and one Unstageable Pressure Ulcer. Review of Resident #11's Care Plan initiated on [DATE] and revised on [DATE] revealed the following: 1. Resident #11 has pressure injuries related to immobility and bowel incontinence. The following interventions were initiated [DATE]: Administer treatments as ordered and observe for effectiveness. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Treat pain as ordered prior to treatment, turning etc. to ensure the resident's comfort. 2. Resident #11 has chronic pain issues related to pressure injuries and impaired mobility. (Initiated [DATE]) Interventions: Administer pain medication as ordered. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Observation on [DATE] at 9:30 AM, revealed LVN A gathering supplies to provide wound care to an Unstageable pressure ulcer to Resident #11's right posterior buttock. LVN A and LVN B entered the room, prepared the supplies and turned Resident #11 to his left side for wound care. LVN A and LVN B did not assess Resident #11's pain prior to beginning wound care. An undated dressing was loosely covering a wound to his right posterior buttocks. Open pressure ulcers were also observed to Resident #11's right upper proximal buttocks and left lateral posterior proximal thigh, which was previously unidentified by the facility. There were no dressings covering the wounds to Resident #11's right upper proximal buttocks or left lateral posterior proximal thigh. The Wound Vac was not in place to the wound on the right posterior buttock per physician's orders [REDACTED].#11's buttocks. Resident #11 grimaced and hollered oh several times clinching his buttocks while LVN A was removing the loose dressing. LVN A and LVN B asked Resident #11 if he was ok and he said no. LVN A then began using Normal Saline to moisten the black [MEDICATION NAME] on the wound bed to loosen the dressing for removal. Each time LVN A used the Normal Saline and attempted to remove the foam dressing, Resident #11 grimaced, hollered oh and clinched his buttocks when the wound was touched. Despite Resident #11's grimacing, hollering oh and clinching his buttocks when the wound was touched, LVN A and LVN B did not ask the resident if he was in pain or if he needed pain medication. Surveyor then intervened and asked LVN A if Resident #11 had been medicated for pain prior to wound care at which time LVN A stopped the wound care, and stated she would give the resident some pain medication. Observation on [DATE] at 11:45 AM, revealed LVN A gathering supplies to resume wound care to Resident #11's Unstageable pressure ulcer. LVN A and LVN B entered Resident #11's room and prepared the supplies for wound care. LVN A and LVN B did not re-assess Resident #11's pain prior to beginning wound care. LVN A and LVN B turned Resident #11 to his left side. LVN A then provided wound care to the newly identified area to his right posterior buttocks without complaints of pain. Without assessing Resident #11's pain, LVN B began moistening the black [MEDICATION NAME] dressing with Normal Saline to loosen the foam dressing. Resident #11 hollered oh and clinched his buttocks as she removed the [MEDICATION NAME] dressing. She then began cleaning the wound with Normal Saline and a 4x4 dressing and Resident #11 stated, It hurts. LVN A then applied a new [MEDICATION NAME] dressing to the wound, removed it and applied [MEDICATION NAME] (a cream applied to the wound bed to control odors) to the wound bed. LVN B told LVN A several times during the wound care, He is still saying it hurts. LVN A continued to provide the treatment to Resident #11's Unstageable pressure area despite Resident #11 continuing to grimace, say oh it hurts and clinching his buttocks whenever the wound was touched. When LVN A was finished with wound care, she stated that she would talk to the doctor and see if she could get an order for [REDACTED]. During an interview on [DATE] at 12:30 PM, the Director of Nurses (DON) stated that she would expect the nurses to assess the resident's pain prior to wound care and stop the treatment if a resident complains of pain. The DON stated, I talked to Resident #11 this morning and he said that he does experience discomfort and pain with treatments (wound care). I talked to the Wound Care Consultant Physician this morning who is discontinuing the Wound Vac. I also spoke with the Medical Director who has ordered routine [MEDICATION NAME] (a liquid pain medication containing [MEDICATION NAME]) 30 minutes prior to wound care. Review of Resident #11's Order Summary Report for [DATE] through [DATE] revealed the following orders: 1. [MEDICATION NAME] (a mild pain reliever) 50mg 1 tablet by mouth (PO) at bedtime (hs) for pain. 2. [MEDICATION NAME] 50mg 1 tablet PO every 6 hours as needed (PRN) for pain. 3.Clean the right posterior buttocks with Normal Saline, apply [MEDICATION NAME] 1% (a cream used to decrease odors) apply Collagen (used to promote wound healing), apply black [MEDICATION NAME] to fit wound bed and attach Wound Vac bridged to anterior thigh. Wound Vac to function at 125mmHG continuous and to be changed on Monday, Wednesday and Friday evenings and as needed. There were no other wound care orders. Review of Resident #11's Medication Administration Record [REDACTED]. Resident #11 had not received any pain medication on [DATE] prior to wound care. Review of a current facility policy titled, Skin Management (revised [DATE]) revealed the following: Overview: Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Stage II Pressure Ulcer Suggested Interventions: 1. Resident, family and attending physician are notified of development of a Stage II ulcer. 3. Care Plan and Assignment Sheet/Care Kardex are updated to reflect new problem and interventions. 5. Resident is added to 24 hour report. Review of a current facility policy titled, Pain Management (revised [DATE]) revealed the following: 10. The staff will implement the Care Plan, monitor the resident and administer therapeutic interventions for pain, if ordered. B. Review of Resident #2's Face Sheet dated [DATE] revealed an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's MDS (Minimum Data Set) dated [DATE] revealed the following: The Resident Usually understands and is Usually Understood. Resident #2's Cognitive Skills for daily decision making was scored as a 3, Severely Impaired - never/rarely made decisions. Review of Resident #2's Care Plan with a revision date of [DATE] revealed that she has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Dementia, Limited ROM (Range of Motion). Observation on [DATE] at 4:00 PM revealed Resident #2 sitting in a Broda chair in the hallway on hall 600. Resident #2's head was bent down almost to her knees. She was crying and holding the right side of her head. The surveyor asked if she hurt and Resident #2 stated I have a headache. It is the worst headache I've ever had. The surveyor reported Resident #2's pain to RN N and RN N stated that she had given Resident #2 pain medication one half hour earlier. The RN N did no assessment until the surveyor asked her to take the resident's blood pressure. RN N placed a wrist blood pressure cuff on Resident #2's left wrist. She placed the cuff so that the display (which shows blood pressure reading) was on the top of her forearm and placed Resident #2's wrist at heart level on the Resident's chest. When informed by the surveyor that the display should be on the inside of the wrist to obtain the reading, RN N stated Then I couldn't read it. Observation of the blood pressure wrist cuff on [DATE] revealed a picture on the cuff showing how to place the cuff to get a blood pressure reading. The picture showed the cuff with the display on the inner surface of the forearm above the wrist. During an interview on [DATE] at 7:00 PM, the Director of Nurses stated that the facility doesn't allow the staff to use wrist blood pressure cuffs. She stated that Resident #2's blood pressure had been retaken using a cuff according to facility policy. She stated Resident #2's blood pressure was high and they had administered a PRN (as needed) blood pressure medication. Review of Resident #2's Nursing Note dated [DATE] at 1850 (6:50 PM) revealed the following: Resident is crying c/o (complaints of headache. B/P Blood pressure ,[DATE] manual, pulse 70, 02 (oxygen) 91% on room air. Attempted to administer [MEDICATION NAME] and Tylenol without success. Will crush and put in drink. C. Review of Resident #18's Face sheet revealed a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. During initial tour on [DATE] at 9:45 AM, LVN K identified Resident #18 as being alert, oriented to person, place, events, and would be interviewable. During an interview on [DATE] at 11:00 AM Resident #18 stated that he had pain when staff was performing wound care. He stated that the facility had been out of his pain medication for months. Observations of the medication cart for hall 400 (Resident #18 resides on hall 400) revealed no narcotic count sheet for Resident #18's Tylenol #3 and no Tylenol #3 in the medication cart. During an interview on [DATE] at 11:10 AM, RN J stated I don't know how long he hasn't had any Tylenol #3. I haven't received any complaints of pain from him. We have been discussing D'Cing (discontinuing) the Tylenol #3. During an interview on [DATE] at 11:25 AM, the Nurse Practioner stated that she didn't know if she had received any request to refill Resident #18's Tylenol #3. She stated The Pharmacist sends requests. There are so many residents in other facilities. I don't keep up with who has refill requests. I just sign them. During an interview of [DATE], the DON stated that Resident #18's Tylenol #3 was now in the facility. She stated that the triplicate (a special prescription form for a narcotic medication) had expired and that they had the triplicate redone by the resident's physician. Review of Resident #18's Face Sheet revealed a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Physician order [REDACTED]. Start Date: [DATE] Tylenol with [MEDICATION NAME] #3 Tablet ,[DATE] mg Give 1 tablet by mouth every 4 hours as needed for pain. Start Date: [DATE] Tylenol with [MEDICATION NAME] #3 Tablet ,[DATE] mg Give 2 tablets by mouth every 4 hours as needed for pain. Review of Resident #18's computerized Physician order [REDACTED]. D. During an interview on [DATE] at 11:30 AM, the Administrator stated that the facility did not have policies and procedures for Dementia residents. He stated that the facility will be implementing training and new procedures, but they were not in place at this time. During a confidential interview on [DATE] a staff member stated that she had no training in caring for dementia residents before she was assigned to work in the secure unit. The CMS 672 form dated [DATE] revealed 58 residents with a [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to ensure residents receive proper treatment and care to maintain good foot health for 1 of 3 residents reviewed for quality of care. (Resident #22) Resident #22 did not receive timely nail care when she complained of pain to the toes on her right foot. This deficient practice affected 1 resident and could affect 2 other residents who are dependent upon staff for proper foot care by causing pain and diminished quality of life. Findings include: Review of Resident #22's Summary of Physician order [REDACTED]. During initial tour on 12/27/16 at 8:40 AM, Licensed Vocational Nurse (LVN) C, Unit Manager stated that Resident #22 was interviewable with intermittent confusion. During an interview on 12/29/16 at 4:20 PM, Resident #22 stated that her toes hurt and her toe nails needed to be trimmed. She stated that she had been telling the staff that she needed her toe nails trimmed for about 4 months. She stated that her family had purchased her a new pair of shoes in a larger size to help with the pain, but she was unable to wear them because of the pain in her toe nails on her right foot. Resident #22 stated that her big toe nail is very thick and causes her pain. Observation on 12/29/16 at 4:20 PM revealed Resident #22 pulling off her house shoe and placing her foot on the bedside table revealing the toe nails on her right foot. The nail on her big toe was discolored and appeared thick. The toe nail on her fourth toe was growing to the left side and was long enough to cross over the third toe. All toe nails on her right foot were long and discolored. She then removed the house shoe on the left foot and stated that underneath the toes on that foot hurt. The area appeared slightly red. During an interview on 12/29/16 at 4:25 PM, Registered Nurse (RN) N stated that Resident #22 is offered pain medication when she complains of pain. RN N stated that Resident #22 is on the list to see the Podiatrist. LVN P, Unit Manager stated that Resident #22 is on the list to see the Podiatrist. The Unit Manager did not offer to contact her Primary Care Physician or another Podiatrist. Review of Resident #22's Skin - Head to Toe Skin Checks dated 11/29/16, 12/7/16, and 12/28/16 revealed the following: 5. Nails Cleaned and trimmed? No During an interview on 12/29/16 at 5:35 PM, the Director of Nurses (DON) stated that Resident #22's husband said his wife had always had problems with her toe nails. The DON stated that Resident #22 was on the list to see the Podiatrist. Three residents were reviewed for nail care.