Every finding on record at Morningside Manor

Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 4 (Resident #4) residents reviewed for MDS assessments. The facility failed to complete Resident #4's Quarterly MDS Assessment within three months of their most recent comprehensive assessment. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information for their care plans. Findings included: Record review of Resident #4's admission Record, dated 04/11/2026, revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (narrowing of the spinal canal compressing nerves causing pain, numbness and leg cramping), diabetes (chronic condition characterized by high blood sugar levels cause by insulin resistance or lack of insulin production), anemia (low levels of red blood cells which transport oxygen in the blood causing pale skin and fatigue) and high blood pressure. Review of Resident #4's Annual MDS assessment dated [DATE] revealed the resident had no cognitive impairment with a BIMS score of 14 out of 15. Review of Resident #4's electronic health record under the MDS tab revealed there was not a more recent MDS Assessment submitted since 12/04/2025; the next ARD for the first Quarterly MDS Assessment was due 03/06/2026 and the Quarterly Assessment was 22 days overdue. In a telephone interview on 04/11/2026 at 4:40 p.m., MDS Nurse LVN C stated he would complete the residents' MDS's according to the schedule generated by the Electronic Health Record. MDS Nuse LVN C stated Resident #4's Quarterly MDS should have been completed on 03/06/2026 and was something that he had missed, and the harm in not completing a Quarterly MDS in the required time could result in the resident's care plan not being accurate. In an interview on 04/11/2026 at 4:55 p.m., the DON stated MDS Nurse LVN C was responsible for completing residents' MDS and then she would review them for accuracy. The DON stated Resident #4's last MDS assessment was an Annual Assessment completed on 12/04/2025, the next MDS Assessment was due on 03/06/2026 and she was not sure what happened to cause the MDS to not be completed. The DON stated the harm of not having the Quarterly MDS completed on time could result in the resident's care plan not being updated if there was a change in the resident's level of care. In an interview on 04/11/2026 at 5:12 p.m., Executive Director B stated they audit residents' MDS weekly to ensure they were accurate and current. Executive Director B reviewed Resident #4's electronic health record, stated an Annual MDS Assessment was completed on 12/04/2025 and the next MDS Assessment should have been completed in March 2026, but no harm came to the resident. Record review of the policy MDS 3.0 Completion, dated 2025, revealed Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of reach resident's functional capacity, using the RAI specified by the state.e. Quarterly Assessment - completed using an ARD no >92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD).

Based on interviews and record reviews, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 2 residents (Resident #1) reviewed for neglect. The facility failed to ensure the previous Executive Director A followed the facility's Abuse Prevention Program policy, when she did not complete an investigation of neglect that involved Resident #1 and did not submit a 3613A Provider Investigation Report to HHSC. This failure could place residents at risk of not being provided with services to meet their needs or prevent them from being neglected.Findings include: Record review of Resident #1's admission Record, dated 04/11/2026, revealed the resident was an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (chronic condition characterized by high blood sugar levels cause by insulin resistance or lack of insulin production), anemia (low levels of red blood cells which transport oxygen in the blood causing pale skin and fatigue), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), cerebral infarction (stroke), and high blood pressure. Record review of Resident #1's Quarterly MDS Assessment, dated 03/05/2026, revealed the resident had short-term and long-term memory problems, and her cognitive skills for daily decision making were severely impaired. Record review of Resident #1's Care Plans revealed a care plan for Resident #1 experiencing alteration in mood/behavior patterns as evidenced by easily annoyed; .racist, false accusations, refuses psych services, refuses certain staff related to being racist. Resident #1 will refuse care from staff if she thinks you are not affiliated with her political views with an initiation date of 03/13/2024. Interventions included to allow Resident #1 to verbalize emotions and validate feelings. Record review of Resident #1's Physician History & Physical, dated 03/17/2026, revealed she was admitted to the hospital on [DATE] for a urinary tract infection and new diagnosis of congestive heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's needs, causing blood to back up and fluid to accumulate in the lungs and body) and was transferred back to the facility on [DATE]. Record review of Incident Investigation Worksheet for Intake #1028885, received 08/07/2025, revealed Executive Director A reported the Marketing Liaison was informed by hospital staff Resident #1 stated that she was unsure about returning to the facility because the resident thought the nursing home staff may be neglecting her because they did not share the same political views. The Executive Director had notified appropriate parties, an in-service on abuse and neglect was initiated. Record review of TULIP on 04/11/2026 revealed that no 3613A Provider Investigation Report had been submitted to HHSC for Intake #1028885. In an interview on 04/11/2026 at 10:41 a.m., Resident #1 stated the staff were not listening to me. When asked for clarification, Resident #1 started talking about how the facility used to have more channels on the TV and now there were 2 channels that were no longer available. When asked again how the employees treated her, Resident #1 restated they don't listen to me and did not elaborate, or give an example, or name an individual. In an interview on 04/11/2026 at 10:58 a.m., Executive Director B stated he started working at the facility in November 2025 and all that he could find for the facility's investigation for Incident #1028885 were a couple of emails to a HHSC Surveyor D and the Preliminary Findings form from the August 2025 annual recertification survey, which he provided to the surveyor. In an interview on 04/11/2026 at 11:27 a.m., the DON stated during the facility's annual recertification survey in August 2025, they received a call from their Marketing Liaison who reported a hospital case manager informed the Marketing Liaison that Resident #1 had reported she felt neglected, so the facility did a self-report. The hospital also filed a complaint against the facility that involved Resident #1 that was investigated by the survey team. The DON stated the previous Executive Director A had asked a surveyor from the survey team if an investigation report was needed for Incident #1028885, but she did not know what the surveyor's response was. The DON stated she could not find a completed 3613A Provider Investigation Report for Intake #1028885 and could only find email communication the previous Executive Director had with a surveyor. In a further interview on 04/11/2026 at 11:58 a.m., Executive Director B stated he was able to find the in-services and resident safe surveys that were done for Incident #1028885. In a telephone interview on 04/11/2026 at 1:07 p.m. the previous Executive Director A stated she had been the facility's Executive Director from October 2023 to September 2025. Executive Director A said she remembered being notified by the facility's liaison or the hospital case manager that Resident #1 had expressed that she was not sure if she wanted to come back to the facility because the resident felt staff were holding things against her because of the resident's political views. Executive Director A stated she reported it to HHSC since the hospital case manager was questioning if the facility was a safe place for the resident to return to, which Resident #1 did choose to return to. Executive Director A said she thought she had completed an investigation and a 3613A Provider Investigation Report that was submitted to HSHC via email. Executive Director A stated she did not remember what HHSC Surveyor D's response back to her was when she asked about the need to complete the investigation report for Incident #1028885. Executive Director A said Resident #1 had a history of making allegations in the past that were care planned. In a further interview on 04/11/2026 at 4:06 p.m., Executive Director B stated they found an encrypted email Executive Director A had sent HHSC on 08/08/2025 but they did not have the password to the encrypted file, so they were not able to provide a 3613A Provider Investigation Report for Incident #1028885. Record review of the HHSC LTCR 3701 Preliminary Findings form, dated 08/07/2025 signed by HHSC Surveyor D and Executive Director A, revealed Incident #1028885 was not investigated during the annual recertification survey that was conducted from 08/05/2025 to 08/07/2025, but Complaint #1028516 was investigated. Record review of an email dated 08/07/2025, sent at 4:06 p.m. from Executive Director A to HHSC Surveyor D, revealed the Executive Director wrote she was working on her investigation report [for Intake #1028885], and wanted to know if the surveyor wanted the items shared with her as the Executive Director gathered them or have them submitted in one complete report once everything was complied. There was no indication in the email what HHSC Surveyor D's response was. Record review of an email dated 08/08/2025, sent at 4:42 p.m. from Executive Director A to HHSC Surveyor D, revealed the Executive Director had a follow-up question regarding the self-report for Resident #1 related to neglect. When you exited, you mentioned that a 5-day investigation was not required as the submission was determined to be a complaint and was unsubstantiated by the survey team. However, today I received an email from the HHSC Complaint and Incident department requesting that I submit my investigation report. Would you still recommend that I proceed with submitting it under these circumstances? I did reach out to my program manager but have not yet heard back. There was no indication in the email what HHSC Surveyor D's response was. Record review of an email dated 08/08/2025, sent at 1:43 p.m. from HHSC Complaint and Incident division to Executive Director A, had the subject line Submission, Self-Report, Morningside Manor with an encrypted attachment and there were no comments in the email. Record review of the facility's Abuse Prevention Program policy, revised 09/02/2009, revealed Reporting: Anyone who has reasonable cause to believe that a resident is in a state of abuse, neglect or exploitation must report it immediately to the Department Director or Administrator. The Department Director must then report to Administrator; who will in turn report to the .state office upon learning of the allegation. The investigation is to be initiated. The Administrator must follow internal policies that pertain to abuse, neglect and exploitation. A written report of the investigation is to be sent to [HHSC] no later than the fifth calendar day after the oral report.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 9 reviewed for pharmaceutical services, in that: LVN A administered the expired insulin to Resident #4, Resident #22, and Resident #74. This failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.Findings included: Review of Resident #4's face sheet, dated 8/6/2025, revealed the resident was a [AGE] year-old admitted on [DATE] with diagnoses of type 2 diabetes and stroke. Review of Resident #4's active order list, there was an order for Lantus Solostar Subcutaneous Solution Pen-injector 100unit/ml (insulin Glargine), start date 3/8/2025. Review of Resident #22's face sheet, dated 8/6/2025, revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes with hyperglycemia (high blood sugar). Review of Resident #22's active order list, there was an order for Novolog Flexpen Subcutaneous Solution Pen-injector 100unil/ml (insulin aspart), start date 3/30/2025. Review of Resident #74's face sheet, dated 8/6/2025, revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses of congestive heart failure and type 2 diabetes. Review of Resident #74's active order list, there were 2 orders for insulin: Insulin Lispo Subcutaneous Solution Pen-injector 100unit/ml (insulin Lispo) with a start date of 6/30/2025; and Lantus Solostar 100unil/ml Solution pen-injector with a start date of 6/30/2025. Observation on 8/6/2025 at 9:04am revealed on LVN A's nurse cart, there were the following insulin pens:_Lantus Solostar (insulin glargine) for Resident#4 that did not have an open date._Novolog Flexpen (insulin aspart) for Resident#22 with an open date of 6.24_Insulin Lispo for Resident#74 with an open date of 5/23/2025._Lantus Solostar for Resident #74 that did not have an open date. In an interview with LVN A on 8/6/2025 at 9:07am, he stated that insulin pens should be labeled with an open date and once opened, the insulin pen should be discarded after 28 days. He admitted that he forgot to check his carts for expired insulin pens and label them accordingly. LVN A also stated that he had been administering the above insulin to Resident #4, Resident#22, and Resident #74. He stated that the risk of giving residents expired medication include adverse reaction, hyperglycemia or hypoglycemia. Review of Resident#4's medication administration log revealed on 8/6/2025 at 7am, LVN A administered insulin glargine. Review of Resident #22's medication administration log revealed on 8/6/2025 at 7am, LVN A administered Insulin aspart. Review of Resident #74's medication administration log revealed on 8/6/2025 at 7am, LVN A administered Insulin Lispo. In an interview with the DON on 8/7/2025 at 10:50am, she stated that all nurses were supposed to audit med carts weekly. The DON performed spot checks occasionally on the med carts. The following were to be done during med cart audit: checking for expired medications, discontinuing medications that are not in use, checking for any pens, vials that needed to be dated and labeled, making sure the cart is clean and organized. She stated that the risk of giving residents expired medication included decreased medication potency, adverse effects, and if the medications were insulin, the risks included hyperglycemia or hypoglycemia. The DON also stated that the physician had been notified, and Resident #4, Resident #22 and Resident #74 were assessed for adverse reactions. In a review of the facility's medication administration checklist, called Mock survey medication pass, dated unknown, revealed for injectable medications, nurses were to date vials when opened (i.e., insulin for 28 days). Review of facility's Labeling of medication containers, dated 4/2009, revealed that one of the requirements for individual medication container labeling included .the date that the medication was dispensed.

Based on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 5 medication carts in that: Two insulin pens were not labeled with an open date in Unit 5 nurse med cart.Two insulin pens were expired in Unit 5 nurse med cart. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.Findings included: Observation of Unit 5 med cart on 8/6/2025 at 9:06am revealed there were 2 insulin pens for Resident #4 and Resident #74 that did not have an open date on them. There were also 1 insulin pen for Resident #74 that was opened on 5/23/2025 and 1 insulin pen for Resident #22 that was opened on 6.24 In an interview with LVN A on 8/6/2025 at 9:07am, he stated that insulin pens should be labeled with an open date and once opened, the insulin pen should be discarded after 28 days. He admitted that he forgot to check his carts for expired insulin pens and label them accordingly. In an interview with the DON on 8/7/2025 at 10:50am, she stated that all nurses were supposed to audit med carts weekly. DON performed spot checks occasionally on med carts. She stated the following were to be done during med cart audit: checking for expired medications, discontinuing medications that are not in use, checking for any pens, vials that needed to be dated and labeled, making sure the cart is clean and organized. She stated that the risk of giving residents expired medication included decreased medication potency, adverse effects, and if the medications were insulin, the risks included hyperglycemia or hypoglycemia. In a review of facility's undated medication administration checklist, called Mock survey medication pass,, revealed for injectable medications, nurses were to date vials when opened (i.e., insulin for 28 days). Review of the facility's Labeling of medication containers, dated April 2009, revealed that one of the requirements for individual medication container labeling included .the date that the medication was dispensed. In an observation on 08/07/25 at 11:30 AM and at 11:57 AM, a Treatment cart was unlocked and unattended with the lock mechanism out (indicating it was unlocked) in Unit 5 hallway, against the wall facing outwards to the hallway. Residents and staff were walking by the unlocked Treatment Cart. The facility staff attending to Treatment cart were inside a resident's room and could not see the cart. It was out of view. In an interview with the Treatment PA on 08/07/25 at 11:57 AM, it was revealed herself and a team of other NPs were in the facility doing wound treatments and some were in training, and they had left the Treatment cart unlocked. She did not state the risk of leaving the Treatment cart unlocked, unattended and out of view. Interview on 08/07/25 at 12:06 PM with ADON B revealed, the facility had a contract Treatment NP and her assistant that did treatments for the facility. She said the expectation was the Treatment cart should be locked when staff was not directly working with the cart. She stated the expectation was that even the contracted staff would follow policy and procedures and lock and secure the medication cart when not in use. She said all nursing staff were responsible for securing medications when not in use. She said the potential risk was a resident may get into the cart and grab something. She said it was a safety concern. In an interview with the DON on 08/07/25 at 1:16 PM, she revealed that it was disheartening that it was not her facility staff that left the Treatment cart unlocked. She said the expectation for all staff was that they would follow policy and procedures, and lock and secure the Treatment cart when not in use. She said the risk was unauthorized access to the cart. Interview on 08/07/25 at 3:49 PM with the Administrator revealed, the Treatment Cart should be locked if it was out of sight and staff were not actively working in the cart. She said the expectation was that all staff would follow company policies and procedures and the expectation for contract personnel was to follow facility policies and to always keep the resident safe. Record review of the facility's policy Administering Medication revised in April 2009 reflected 9.During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. Record review the facility's policy Security of Medication cart, revision date April 2009, reflected 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The cart must be locked before the nurse enters the resident's room. 3. Medication carts must be securely locked at all times when out of the nurse's view. 4. When the medication cart is not being used, it must be locked and parked.

Based on observation, interview and record review, the facility must properly dispose of garbage and rubbish in accordance with current state laws for dumpster 1 of 2 reviewed for garbage disposal. The facility failed to ensure the doors on dumpster 1 were secured. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: Observation on 08/05/25 at 8:36 AM, reflected the facility's dumpster area, which was outside of the dietary department to the right side of the parking lot were two commercial size dumpsters. Dumpster 1 had the left and right-side doors open which were 1/2 full of garbage. Interview on 08/05/25 at 8:40 AM, reflected the KD stated the dumpsters were for the entire facility and not just the kitchen. He stated the lids and doors on the dumpsters were supposed to be closed to keep all trash contained. He stated that the risk of the dumpster doors being opened could attract rodents. Interview on 08/05/25 at 3:31 PM, the FSS stated the kitchen and housekeeping were responsible for making sure the dumpsters were closed. He stated that the dumpsters were for the entire facility. He stated that the risk of dumpster 1 being left opened could cause critters to get into the trash. Interview on 08/07/25 at 1:15 PM, the HS revealed the housekeeping department were mainly responsible, but the dumpsters are universal to the entire facility. He stated it is not okay for the dumpster doors to be open. He stated he expected his staff to have a constant diligence on both dumpsters to be sure they were always closed. He stated that the risk of dumpster 1 doors being left open could cause a few different factors such as having unwanted rodents like racoons or skunks, infection control, or a potential of cross-contamination. Interview on 08/07/25 at 4:00 PM, the ADM revealed the dumpsters were community dumpsters, but the dietary department and housekeeping staff mainly used it. She stated she expected her department heads to manage dumpster 1 as a team and keep it closed. She stated the risk of dumpster 1 being left open exposes them to having unsanitary practices or could cause critters to wonder into the trash. Record review of the facility's policy Disposal of Garbage and Refuse, revised on 01/25 stated: Policy: The facility shall properly dispose of kitchen garbage and refuse. Policy Explanation and Compliance Guidelines: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for 1 (Resident #12) of 7 resident reviewed for enteral tube feeding, in that: The facility failed to assess, obtain physician order, care plan, and obtain consent for Resident #12 to self-administer her bolus feedings via the g-tube two times a day. This failure could place residents with G-tubes at risk of needs not met and a decline in resident's health. Findings included: Record review of Resident #12's face sheet dated 8/14/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure), type 2 diabetes, breast cancer, neoplasm of uncertain behavior of pharynx (throat cancer), and difficulty swallowing. Review of Resident #12's quarterly MDS dated [DATE] reflected Resident #12 had a BIMS of 15, indicating cognitive intact. She makes self-understood, and she understands others. The document reflected Resident #12 had a feeding tube and received 26-50% of her nutrition and 500 cc/day or less fluid through the feeding tube. Record review of Resident #12's physician orders for August 2025 reflected: - MIC-KEY G-TUBE 20FR 3.5CM, 5CC BALLOON LAST CHANGE 9/25/24- active 09/25/24. - Enteral Feed Protocol: Hydration Flush every shift Flush enteral tube with 90____ mL of water before and after feeding for hydration. Total volume of water flush _180____ mL/24hr- Active 11/18/22. - Enteral Feed Protocol: Placement every shift Check tube for proper placement by auscultation and inspect stomach contents prior to: - Each Feeding - Flush - Medication administration May obtain x-ray for placement of feeding tube if indicated- Active 11/18/22. - Enteral Feed Protocol: Residual every shift Check for residual by aspirating stomach contents Q shift, if more than 100mL of stomach contents is aspirated, return the contents to the stomach, hold feeding and notify the physician for further instruction- Active 11/17/22. - Residents with PO diets may use house available supplement whenever Ensure or other name brand nutritional supplement is ordered- Active 11/17/22. -Residents with PO diet may have a Regular Diet according to texture modification for monthly activities and holidays- Active 11/17/22. - [Resident#12] may take medications PO or by PEG-tube depending on how she feels regarding her ability to swallow due to her history of throat cancer. every shift related to neoplasm of uncertain behavior of pharynx- Active 12/27/22. -Enteral Feed Protocol: Administration Set and Supplies every night shift Change administration set (spike, cap, and bag) daily on night shift. Date and label with each change. Change syringe/irrigation set daily on night shift- Active 11/18/22. - Enteral Feed Protocol: Cleanse Stoma Site everyday shift Cleanse stoma site with NS, pat dry and apply sterile split sponge if needed Q shift and PRN- Active 11/18/22. - Enteral Feed Order two times a day ([brand name] 1.2) Formula to be administered via bolus _2___ times per day for a total of 474___ cc's and __711_ calories in 24 hours- Active 11/19/25. - Special Diet: REGULAR diet Consistency: REGULAR texture, Liquid: THIN consistency. -The physician orders did not reflect self-administration of eternal feeding by Resident. Record review of Resident #12's care plan initiated 02/7/23 revealed a focus: I have bolus enteral feedings r/t Dysphagia and Chronic fatigue syndrome and have a Regular diet to eat by mouth as I tolerate, family signed wavier.Goal: will receive diet as ordered and will maintain weight over next 90 days Target Date: 05/30/2025Interventions: Provide bolus feeding and flushes as ordered. Observe for nausea/vomiting and report to MD. -The care plan did not reflect Resident #12 could self-administer her own g-tube bolus feeding two times a day via the g-tube. Record review of quarterly nutrition assessment completed on 05/28/25 by Dietitian did not reflect any weight loss concerns. It reflected that Resident #12 liked to do things herself, and her weight was improving with a goal weight of 148 lbs. Record Review of Resident #12's monthly weights reflected no concerns.-8/5/25-120.8lbs-7/10/25- 120.2lbs-5/18/25- 119.5lbs Record review of assessments on 08/5/25, did not reflect a completed self- administration assessment for g-tube bolus feeding two times a day via the g-tube. Record review of consent and waiver did not reflect self- administration consent or waiver for g-tube bolus feeding two times a day via the g-tube. In an observation and interview with Resident #12 on 08/05/25 at 1:30 PM, revealed Resident #12 in her room. She stated she had not eaten lunch, because she did not like the food. She said she was going to do her bolus feeding via her g-tube. She stated she had been trained many years before coming to the facility. She stated she was very comfortable doing her own feeding. No concerns during self-administration of bolus feeding and a new gauze dressing was applied to the MIC-KEY stoma and attachment cleaned and stored after administration of bolus. In an interview with the dietician on 08/05/25 at 2:33 PM, revealed Resident #12 was monitored for weight loss monthly. She said nursing was responsible for assessing and care planning for Resident #12's g-tube self-administration. She said it was important to assess the resident so that you can know that they can safely do the feeding. The Dietitian said she had no input on the care plan and assessment, but she did note on the quarterly nutrition assessment that Resident #12 liked to do things by herself. She said she did not see any risk to the resident self-administering the feeds because she was maintaining and even gaining weight. In an interview at 08/06/25 at 3:21 PM, LVN C said she was assigned to care for Resident #12, and she used to try and do the feeding for Resident #12 when she first moved to the facility but Resident #12 would yell and scream at her. She said Resident #12 does not like anyone to touch her feeding tube. LVN C stated she has monitored Resident #12 as she did her own feeding, and she had no concerns with the procedure. LVN C stated she did not do an assessment for Resident #12 to self-feed, and she did not do the care plans for the residents because it was not in her scope of practice. She said Resident #12 should not be in the skilled facility because she did everything for herself and refused help from the staff. She said Resident #12 is very independent and very mobile. She said that the nurses made sure that all the supplies are changed daily such as the syringe and they made sure that she has the formula. LVN C stated that Resident #12 was up the whole night and slept during the day and she did not want to be woken up. LVN C said that they monitor for infection as well by discarding any open or left over formula and making sure she has cleaning solution for the MIC-KEY attachment. LVN C said there was no risk to Resident #12 self-administering because she's been doing it long before she came here. In an interview on 08/07/25 at 12:06 PM, the ADON B said Resident #12 should be in independent living because she does everything herself. ADON B stated Resident #12 did not like anyone doing her feedings. She said they were monitoring Resident #12's weight and that the G-tube was only used for supplemental when resident had poor oral intake. ADON B said the expectation was that a resident that self-administer got an assessment before they were allowed to self-administer. She said she thought it had already been done prior to her working at the facility. ADON B stated she believed Resident #12 was care planned to self-administer feedings. In an interview with the DON on 08/07/25 at 1:16 PM, she said she went and observed Resident #12 do her feeding today and she had no concerns. She said Resident #12 was very independent and before she came to the facility, she already had the g-tube and was feeding herself. The DON said that she would reach out to the physician and obtain a physician order to self-administer formular via g-tube. She said Resident #12 had a care plan to self-administer but it may have resolved. She said she did not know who had resolved that care plan. The DON said that the ADON had completed a self-administration assessment on of 08/6/25. She said she was responsible for making sure that all care areas were care planned but the nurse could do assessments and get physician orders. She said that if there were any concerns then they would discuss the issues in the morning meetings. She said the expectation was that the nurses would supervise the residents during feeding however for residents that could do it themselves they had the right to do it themselves. She said there was no risk to Resident #12 because she had a high BIMS and could safely self-administer the feeding. The DON said that she was not aware that they needed a consent to self-administer bolus feedings. Record review of a medication self-administration evaluation completed on 08/06/25 for Resident #12 reflected no concerns for self-administration evaluation. Record review of facility Policy Self-Administrating of Drugs, revision date April 2009 reflected: As part of their overall evaluation, the staff and the Attending/On Call Physician will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. 2. In addition to general evaluation of decision-making capacity, the staff and Attending/On Call Physician will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels, b. Comprehension of the purpose and proper dosage and administration time for his or her medications, c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them, and d. Ability to recognize risks and major adverse consequences of his or her medications. Record review of facility Policy Enteral Nutrition revised May 2009 reflected in part 1. The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. 3. A Dietitian will conduct a full nutritional assessment within current initial assessment timeframes. Current Standards of Practice, facility formulary, and facility policies will be the basis for the assessment and recommendations. The Dietitian will confirm or modify initial orders based on the complete nutritional assessment.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #8) of 5 residents reviewed for quality of care. 1. The facility failed to accurately assess Resident #8's bowel and bladder status. 2. The facility failed to accurately access Resident #8's ability to voice her bowel and bladder needs. These failures could place resident with having inaccurate care plans and inappropriate identification of care needs. Findings included: Review of Resident #8's annual MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Unspecified Injury of Head, Subsequent Encounter (a healthcare visit that occurs after the initial active treatment of a condition or injury; Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar - glucose); Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause). She had adequate hearing, clear speech, was always understood and had adequate vision with glasses. Her BIMS score was 15, which indicated memory fully intact. She did not have any issues with inattention, disorganized thinking or altered levels of consciousness. Her mood assessment reflected no issues. She had no delusions, hallucinations or psychosis. She was noted to have verbal behaviors towards others and wandering during the assessment period, but no physical behaviors directed towards others. She required limited assistance for bed mobility, locomotion, dressing, eating, toilet use and personal hygiene. She had no range of motion impairments and used a walker and wheelchair for mobility. She needed partial/moderate assistance with tub/shower transfers. It was noted in the MDS she was frequently incontinent with bladder and occasionally incontinent of bowel. No toileting program had not been used. The DON signed as the RN assessment coordinator verifying assessment as complete on 06/08/2025. Review of Resident #8's Bowel and Bladder assessment dated [DATE] revealed Resident #8 was continent of both bowel and bladder. Does not require a toileting plan. Review of Bowel and Bladder assessment dated [DATE] revealed Resident #8 was incontinent of bladder and continent of bowel. Does not require a toileting plan. Review of Resident #8's Plan of Care Tasks History dated 07/15/2025 through 08/07/2025 revealed Resident #8 was continent of bowel and bladder with no episodes of incontinence. On 08/06/2025 at 1:10 PM, interview with DON revealed that Resident #8 is not incontinent of bowel and bladder. Informed DON that Resident#8's MDS noted that resident is frequently incontinent of bladder and had occasional episodes of bowel incontinence. DON stated she will inform the MDS Coordinator to correct the mistake. On 08/07/2025 at 2:47 PM, interview with MDS Coordinator revealed he had worked at the facility since 2014. He works at both buildings. Responsible for all the MDS for building. Completes MDS almost daily. Monday through Friday. The process is to interview residents on paper in person and document information in the MDS program. He evaluated the resident in their room. Completed the MDS within the 14-day window. Every 90 days and if there had been a change in condition and end up in the hospital or a fall. Completed an annual MDS as well. Evaluating vision and hearing the SW completes, looks at progress notes such as shortness of breath when their bed is lowered, assess their skin for any breakdown. When a resident discharged home and return a new MDS is completed. A discharge MDS is completed when they discharged home. If a resident is discharged more than 72 hours from the facility and must return to facility a new MDS will have to be completed. Resident #8 has been labeled as having issues with bowel and bladder incontinence according to the POC. If these questions are answered yes, it will automatically trigger the MDS that resident has a bowel and bladder incontinence problem. The DON revealed resident does not have incontinence. The daily task notes resident is continent. He will go speak with the nurses if he has a question concerning discrepancies with the answer's r/t incontinence. On 08/07/2025 at 4:30 PM, interview with the ADM revealed that the MDS Coordinator completed all the MDS Assessments. The ADM's expectation is that the MDS are correct according to the assessment completed and that he is communicating with nursing staff to ensure accuracy of the assessments. No policy for MDS Accuracy was provided. Facility follows the RAI manual. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1 dated October 2019 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .

Based on observation, interview, and record review, the facility failed to ensure each resident had a right to secure and confidential personal and medical records for 6 (Residents #7, #9, #45, #61, #69, & #74) of 7 residents reviewed for privacy and confidentiality The facility failed to ensure the privacy and confidentiality of resident's clinical records that were not left on top of a treatment cart face up in the hallway unattended from 11:30 AM to 11:57 AM, for Resident #7, #9, #45, #61, #69, & #74 on 08/7/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy and confidentiality. Findings included: Record review of Resident #7's face sheet, dated 8/7/25, revealed a [AGE] year-old male with an initial admission of 09/14/23 and readmitted to the facility on [DATE]. His primary diagnosis was Altered mental Status, other diagnosis included Methicillin Resistant Staphylococcus Aureus infection as the cause of diseases classified elsewhere (MRSA is a type of bacteria that many antibiotics don't work on) and encounter for surgical aftercare following surgery on the genitourinary system (surgery on the urinary system). Record review of Resident #9's face sheet, dated 8/7/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe) and Chronic Peripheral Venous Insufficiency (a condition that occurs when veins in the legs or arms have difficulty returning blood to the heart). Record review of Resident #45's face sheet, dated 8/7/25, revealed an [AGE] year-old male admitted on [DATE] with a diagnoses of primary osteoarthritis right shoulder (this is a type of arthritis that occurs when flexible tissue at the ends of bones wear down) and non-pressure chronic ulcer of right heal and midfoot with other specified severity, pressure ulcer of right heal unstageable, and benign neoplasm of the parotid gland (cancer of the parathyroid gland located in the neck). Record review of Resident #61's face sheet, dated 8/7/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Vascular dementia (this is brain damage that is caused by multiple strokes that causes memory loss) and Type 2 Diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels). Record review of Resident #69's face sheet, dated 8/7/25, revealed an [AGE] year-old male with an initial admission of 7/25/23 and readmitted [DATE] with a primary diagnosis of traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter (head injury resulting in consciousness of 30 minutes or less). Record review of Resident #74's face sheet, dated 8/7/25, revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses of congestive heart failure and type 2 diabetes. Continuous observation on from 11:30 AM to 11:57 AM on 08/07/25 revealed 7 pages of residents' medical records spread on top of the treatment cart in the unit 5 hallway. The medical records were titled [facility name] dated 08/7/25. The documents had 6 columns, with handwritten notes in red ink as follows; first column had names of residents, second column had location of wound, third column had the stage of wound, the fourth was blank, the fifth had the treatments, and the sixth had the frequency. The documents were visible, face up, near resident's rooms and unattended on top of the treatment cart by the wall in unit 5 hallway with Residents # 7, #9, #45, #61, #69, & #74's medical records displayed. In an interview with the Treatment PA Assistant on 08/07/25 at 11:54 AM, it was revealed herself and a team of other NPs were in the facility doing wound treatments. She stated, oops we have been dinged for HIPPA, as she gathered the papers with the resident's medical records from the top of the treatment cart. When asked by Surveyor about the risk of leaving residents information out, Treatment PA did not state the risk of leaving residents information unattended and accessible to unauthorized persons. In an interview with the DON on 08/07/25 at 1:16 PM, she stated all medical persons are trained on HIPAA to protect resident information and privacy. She said every staff member is trained on HIPAA. She said she expected the contracted treatment team members to flip over the papers with residents' information, or best practice was to take document with them. She said she expected everyone to protect resident's records. She said the risk was access of resident's information to unauthorized persons. Interview with the ADM on 08/07/25 at 3:49 PM, she stated she expected all staff to handle clinical records with confidentiality. She said she expected staff to close, turn off, or lock computer screen when not in use. She said all staff were taught to protect resident information when they were hired. She said if documents were on paper, she expected staff to take it with them and to secure it. She said it was the staff's responsibility to make sure documents were secure. The ADM said that she had reached out to corporate office to request that the contracted treatment company not return to the facility. The ADM said risk of leaving residents information exposed was a breach of resident's privacy. Record review of the facility's policy titled Confidentiality of Information and Personal Privacy revised 12/15/ 2017 revealed: .the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records

Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. The right to participate in establishing the with the resident and the resident's representative for 3 of 5 residents (Resident #8, Resident #48, and Resident #69) reviewed for Comprehensive Care Plans in that: The facility failed to ensure Resident #8, Resident#48, and Resident #69 or the resident's representative were invited to participate in the residents' care plan meeting. This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their care. Findings include: Record review of Resident # 8's face sheet dated 08/07/2025, revealed a [AGE] year-old female, admitted to facility on 05/19/2023. Her diagnoses included: Unspecified Injury of Head, Subsequent Encounter (a healthcare visit that occurs after the initial active treatment of a condition or injury; Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar - glucose); Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause). Record review of Resident #8's file revealed that resident participated in a care plan meeting with the facility team on 08/26/2025 at 1:56 PM. There was a care plan documented on 05/22/2025 with no care plan meeting documented as held with resident. The last previous care plan meetings held with resident were documented 09/12/2024. On 08/06/2025 at 11:16 AM, an interview with Resident #8 revealed she has attended a care plan meeting with the facility team but could not provide a specific date. Resident #8 does not wish for her nieces to attend her care plan meetings. Resident #8 is her own responsible party. Record review of Resident #48's face sheet dated 08/07/2025 revealed an [AGE] year-old male, admitted to facility on 07/16/2025. His diagnoses included: Wedge compression fracture of second lumbar vertebra, subsequent encounter with routine healing (a type of spinal fracture where the front part of the vertebra collapses, take a wedge shape); Type 2 diabetes mellitus with chronic kidney disease (a serious complication that develops over time when blood sugars and blood pressure are not well controlled); Acute Kidney Disease (a condition in which the kidneys suddenly can't filter waste from the blood). Record review of Resident #48's file revealed documentation noted in SW notes that family was contacted to attempt to have a care plan meeting on 07/22/2025. No documentation a care plan meeting held with resident or family on 07/22/2025. On 08/06/2025 at 12:10 PM, an interview with Resident #48 revealed he does not remember if he had a care plan meeting with the facility team. It was noted on the resident's face sheet that he was his own responsible party, and he had two brothers. Record review of Resident #69's face sheet dated 08/07/2025 revealed an [AGE] year-old male readmitted to the facility on [DATE]. Resident was admitted for skilled services on 07/25/2023 before discharging home. His diagnoses included: Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter (a global ischemia, resulting from a lack of perfusion of pressure during aneurysmal rupture: a brain aneurysm that bursts); Epilepsy, unspecified, not intractable, without status epilepticus (a group of disorders marked by problems in normal functioning of the brain); Chronic Atrial Fibrillation, Unspecified (an irregular and often very rapid heart rhythm). Record review of Resident #69's file revealed no documentation for initial care plan meeting with resident or resident representation. It was noted on Resident #69's face sheet that he was his own responsible party and has two sons and two daughters. On 08/06/2025 at 12:47 PM, an interview with Resident #69's family member revealed he believed that there has been a meeting in the past when Resident #69 was at facility last year. Family member stated the facility keeps the family well informed. On 08/07/2025 at 10:20 AM, an interview with the SW revealed that she had been employed at the facility as of 11/01/2024. The SW revealed that she tries to keep up with the documentation when care plan meetings are held. The SW does not use the Family/Resident Conference Form located in the facility's assessment task. SW stated she was not trained to use that form. The SW revealed she documented in the SW progress notes. The process the SW used to invite the residents and family members to the care plan meetings was by calling them or by emails. She personally invited the residents. The goals were to ensure that the residents or their representatives was invited to participate in the care plan meetings and documentation is completed during the meetings. Record review of the facility's Comprehensive Care Plans (revised November 2010) revealed in part, Our facility's Care Planning/Interdisciplinary Team in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Resident #1) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions to address Resident #1's use of anti-coagulant medication, bed rails, and walker. This failure could have placed residents at risk of not having their needs identified and met. The findings included: Record review of Resident #1's admission Record/Face Sheet, dated 08/06/2025, revealed an [AGE] year-old female who originally admitted to the facility on [DATE] with most recent admission on [DATE]. Resident #1 was noted to have diagnoses of Alzheimer's Disease (a progressive brain condition that slowly damages your memory, thinking, learning, and organizing skills), Vascular Dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), Anxiety (intense, excessive, and persistent worry and fear about everyday situations), Unspecified Asthma (condition that causes airways to swell, narrow, and fill with mucous; can make it hard to breathe or cause chest tightness, cough and wheezing), Chronic Obstructive Pulmonary Disease (term for lung airway diseases that restrict breathing; airway inflammation and scarring, damage to the air sacs in the lungs, or both), Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris (hardening of arteries from plaque building up gradually inside them; plaque consists of fat, cholesterol, and other substances), Chronic Diastolic (Congestive) Heart Failure (a stiff left heart ventricle; when the left heart ventricle is stiff, it doesn't relax properly between heartbeats), Chronic Constrictive Pericarditis (condition where the pericardium, the thin membrane that holds the heart in place, becomes stiffer and thicker than normal, keeps the heart from beating properly and can cause severe complications over time), Atrial Flutter (type of heart rhythm disorder, called an arrhythmia, in which the heart's upper chambers beat too quickly), and Chronic Atrial Fibrillation (occurs when abnormal heart rhythms last more than a week; common persisting symptoms include palpitations, shortness of breath, fatigue, chest pain, dizziness, and stroke). Record review of Resident #1's Baseline Care Plan, dated 07/04/2025, revealed the resident was able to communicate with and understand staff, had adequate hearing and vision, and was a full code status (in the event of cardiac or respiratory arrest, a patient's medical team will employ all available life-saving measures). Resident #1's admission and discharge goals were Assisted Living, with initial discharge goals of remain in the facility selected and no discharge plans initiated. Resident #1's functional status was noted to be Independent in all categories. The category of Mobility Devices indicated a walker was normally used by Resident #1. Resident #1 was noted to use Anticoagulants in the Medications category and was indicated to not self-administer medications. The Baseline Care Plan for Resident #1 had no Social Services notes. Baseline Care Plan for Resident #1 was signed by LVN D. Record review of Resident #1's Orders, dated 08/06/2025, revealed orders for TRANSFER ASSISTIVE DEVICE: X2, 1/4 bed rails up as per Dr.s orders while in bed, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN (as needed) to avoid Injury. Pharmacy orders included Apixaban for A-FIB (atrial fibrillation), Klor-Con for Afib, Carvedilol for HTN (hypertension; high blood pressure), Hydralazine for HTN, Isosorbide Mononitrate for HTN, Losartan Potassium for HTN, Nifedipine ER Osmotic Release for HTN, Memantine HCL for Alzheimer's disease, and Donepezil HCL for dementia. Record review of Resident #1's Comprehensive MDS, dated [DATE] for reentry admission on [DATE], revealed Hearing, Speech, and Vision were all in the adequate and understood ranges. Resident #1 had a BIMS (structured evaluation aimed at evaluating aspects of cognition in elderly patients) summary score of 04, indicating severely impaired cognition. Functional Abilities for Resident #1 were indicated to be no impairment for upper or lower extremities, resident utilized a walker to assist with mobility and was independent with mobility except for bathing in which Resident #1 needed partial/moderate assistance. It is noted that Resident #1 was at risk for pressure ulcers. Resident #1 was noted to take the following High-Risk Drug Classes of Anticoagulant, Antibiotic, and Diuretic. Care Ares triggered for Resident #1 included Cognitive Loss/Dementia resulting in BIMS assessment, Nutritional Status resulting in Nutritional Therapy admission Assessment, Dehydration/Fluid Maintenance resulting in dehydration risk screen, and Pressure Ulcer resulting in a Braden Scale (risk assessment tool for predicting pressure ulcers). The MDS was signed by DON as both RN Coordinator for CAA (Care Area Assessment) on 07/17/2025 and Person Completing Care Plan Decision on 07/24/2025. Record review of Resident #1's ongoing Care Plan, initiated on 07/08/2025, revealed that focus areas of Potential nutritional problem r/t weight loss/gains, dehydration, pain/discomfort; DNR-DO NOT RESUSCITATE; Independent for meeting emotional, intellectual, physical, and social needs; and Discharge Goals, have Goals and Interventions/Tasks, however no other Focus Areas are included in the Care Plan. Interview on 8/7/25 at 12:10 PM, LVN A revealed an experienced nurse with over 10 years longevity at the facility and good knowledge of residents. LVN A informed that when a new resident admitted to the facility, the nurse on shift for the unit admitting to would welcome the individual, make sure immediate needs were met, took vitals and weight, obtained information from resident/family or hospital on abilities, needs, preferences, ensured orders were entered into the electronic healthcare record, confirmed the orders with facility medical director, ensured a diet slip was completed and taken to the kitchen so resident would get next meal served, then work on medication reconciliation so medications could be ordered. LVN A stated that the nurses would complete assessments of new residents including baseline assessment, transfer assessment, skin assessment, pain assessment, etc. LVN A stated that the care plan meetings were attended by the DON and ADON's to represent nursing and update associated care plan areas, care plan meetings were held quarterly, and any major or significant changes that were discussed were relayed to other nursing staff verbally; nursing staff were not really informed about minor changes from care plan meetings. Interview on 8/7/25 at 12:20 PM, CNA E, who also works as a Medication Technician, revealed an experienced staff member with over 10 years of longevity with the facility. CNA E stated that when a new resident admitted to the facility, staff were to introduce themself, make sure vitals and weight had been taken, orient the resident to the call light and make sure it was within reach, and ask about preferences from a family member or resident directly. CNA E stated that conversation with the nurse about other information, like for pain management, would take place once resident settled in. CNA E stated that charting in the electronic health record was completed by nurses; CNA's and Medication Techs could document completion of tasks such as incontinent care, feeding or meal completion amounts, showers, etc. was documented as they only had access to that one screen on their tablets with the specific tasks they do. CNA E stated that CNAs were able to see resident assessments however did not look at them very often; a resident care plan was sometimes looked at as specific interventions could be seen. CNA E stated that it would have been a concern if a care plan had little to no information on it and would tell the DON right away. Interview on 8/7/25 at 12:51 PM, the DON revealed that care plans should include information on anything the facility or staff were providing for resident. The care plan was to be checked and updated on a resident's change of condition, significant change, quarterly, when a new assessment was required, annually, and during any care plan meetings with the interdisciplinary team and resident/family. The DON stated that a baseline care plan was to be completed within 48 hours of admission of a resident, a comprehensive care plan was to be completed within the first 7 days of admission. The DON stated that a comprehensive care plan should be completed by the RNs and were based off of the assessments competed by the LVNs at admission that trigger the care plan areas; certain medications when entered into a resident's electronic health record would also trigger care plan areas as well as some diagnosis. The DON stated that medications used as an anticoagulant should have triggered the care plan area as having needed to be completed. The DON stated that the comprehensive resident-centered care plan was important so that all staff knew how to care for the resident, what interventions to use or avoid, what the focus and goals were and what was needed to be done for resident. The DON was asked about Resident #1 in specific and when the resident's care plan was accessed, the DON agreed the care plan was lacking for anticoagulant, hospital discharge, and other care area information. The DON agreed that the comprehensive person-centered care plan for Resident #1 was incomplete. The DON stated that resident needs could go unmet with the lack of a completed comprehensive care plan. Record review of the facility's policy titled Care Plans - Comprehensive, from the Nursing Services Policy Manual Morningside Ministries (Revised November 2010), revealed: Developing the Comprehensive Care Plan- 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.Purpose of Care Plan- 3. Each resident's Comprehensive Care Plan has been designed to: a, Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care; f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and g. To attain or maintain the highest practical functioning of the resident.Time Frame for Completing the Care Plan- 4. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #45) of 7 residents reviewed for infection control. The facility failed to follow EBP (Enhanced Barrier Precautions) procedures for Resident #45 when the wound treatment team failed to wear PPE while providing wound care to Resident #45 on 08/07/25. This failure affected residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #45's face sheet, dated 8/7/25, revealed an [AGE] year-old male admitted on [DATE] with a diagnoses of primary osteoarthritis right shoulder (this is a type of arthritis that occurs when flexible tissue at the ends of bones wear down) and non-pressure chronic ulcer of right heal and midfoot with other specified severity, pressure ulcer of right heal unstageable, and benign neoplasm of the parotid gland (cancer of the parathyroid gland located in the neck) Record review of Resident #45's quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating cognitively intact. Further review of MDS indicated Resident #45 had a diabetic foot ulcer and required application of dressings to feet. Record review of Resident #45's care plan, dated 07/01/25, revealed the Resident #45 was at risk for infection and was on enhanced barrier precautions r/t wound at risk for multidrug resistance organism. Wear gowns and gloves for high contact resident care activities with a goal of resident not showing any signs and symptoms of infection. Interventions included: Educate Resident / Representative on infection control practices, Educate Resident / Representative on techniques to prevent infection, such as handwashing, adequate rest, nutrition and avoidance of crowds and Evaluate wounds for signs / symptoms of infection. Record review of Resident #45's physician orders for August 2025 reflected:-Enhanced Barrier Precautions r/t wound care. at risk for multidrug-resistance organism. wear gowns and gloves for high-contact resident care activities. Every shift. Order active 07/01/25.Record Review of Resident #45's treatment note dated 08/05/25 by wound physician reflected: Wound #1 Location: Right heel 1.5cm x 0.9cm x 0.1cmPrimary Etiology: Diabetic ulcerArea cleansed with wound cleanser and [brand name] solution, patted dry. Applied collagen then calcium alginate with AG [refers to wound dressing that incorporates silver] to wound bed and covered with silicone dressing.20% slough 80% granulation. Moderate serosanguineous drainage [this is drainage that is mixed consisting of thin watery pale-yellow fluid and bloody red fluid]. Periwound callused edges. No odor. No pain Observation on 08/07/25 at 11:30 AM revealed Resident #45's door signage on the door read Gloves and gowns should be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Perform hand sanitation before entering the room and prior to leaving the room. Postings at the resident's room entrance indicating the resident was on enhanced barrier precautions. Resident #45's door was open with privacy curtain slightly halfway. Five staff were observed in the resident's room. Three stood at the foot of the bed and two were providing wound care. None of the five staff were wearing PPE for EBP and of the two providing wound care none wore gowns for EBP. The two staff wore blue gloves. In an interview on 08/07/25 at 11:54 AM, the PA stated they were a contracted wound treatment company, and she had some NP's training with her. She said there were no precaution necessary for Resident #45 for EBP. Pointing to the signage on Resident #45's door, she said Resident# 45 did not have drainage in his wound and did not require to be on EBP. She stated, No risk to resident, he does not have any fluids or infection. Interview on 08/07/25 at 12:06 PM with ADON B revealed she was one of the infection control preventionists. She stated all staff, including contract staff, were expected to follow infection control policy and procedure. She said all the nurse managers and DON were responsible for monitoring infection and implementing infection control training. She said all contract personnels were educated about facility policies and following infection control. ADON B said she was disappointed that the outside company did not follow the facility policies. She said she expected the treatment team that was providing wound care to wear gowns for EBP as per facility policy for EBP. She said the risk was spreading infection. In an interview with the DON on 08/07/25 at 1:16 PM, she stated all staff were expected to use standard infection control precautions including EBP wherever it was applicable. The DON stated she had in serviced on infection control, including EBP, and she was upset that the contract company did not follow the facility infection policy and procedures. The DON said she was responsible for monitoring that infection control precautions were being followed. She said the risk was spreading infection. Record review of the facility's Infection Prevention & Control Tracking Log and Antibiotic Stewardship on 08/06/25, did not reveal an infection pattern in last 90 days. Record Review of the facility's Enhanced Barrier Precautions policy, dated March 2024, reflected, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .1. a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. 2. Initiation of Enhanced Barrier Precautions: a. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. ii. Chronic wounds (pressure ulcers stage III & IV, diabetic foot ulcers, and venous ulcers) > 6 weeks old, even if resident is not known to be infected or colonized with a MDRO. 3. Implementation of Enhanced Barrier Precautions: a. Residents placed on EBP will be identified using an orange star on their name tag outside the door of their room.

Based on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. On 03/23/24, LVN A and LVN C failed to notify the Medical Doctor 3 out of 7 neuro checks were not being done for 12 hours. Resident #6 was hospitalized on [DATE] and returned 03/27/24 with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech . An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 09:00 PM. While the IJ was removed on 06/09/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential harm because all staff not been trained on. The findings were: Record review of Resident #6's admission record, accessed 06/07/24, reflected the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and dementia (neurodegenerative disease that affects memory, thinking and interferes with daily life). It further reflected Resident #6 returned to the facility on [DATE] with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech . Record review of Resident #6's significant change in status MDS, dated [DATE], reflected a BIMS score of 99, indicating resident was unable to complete the interview. Further review of this MDS reflected Resident #6's cognitive skills for daily decision making was severely impaired with short term and long term memory problems. Record Review of nursing progress note, authored by LVN A on 03/22/24 at 01:20 PM, reflected Resident #6's RP reported Resident #6 could not hold her beverage. This progress note further revealed NP B ordered neuro checks Q 4 hrs x 3days, notify NP of any deficit. Record review of Orders- Administration Note , authored by LVN C, reflected: 03/23/24 at 02:02 AM Neuro check was not done due to [Resident #6] being asleep 03/23/24 at 04:55 AM Neuro check was not done due to refusal Record review of Orders- Administration Note , authored by LVN A, reflected: 03/23/24 at 09:06 AM Neuro check was not done due to family member refused since [Resident #6] was sleeping Record review of Resident #6's Medication Administration Record for March, undated, revealed neuro checks that were done were: 03/22/24 at 04:00 PM and 08:00PM, 03/23/24 at 12:00 PM and 04:00 PM. Record review of nursing notes from 03/23/24 revealed no documentation of NP or MD being notified of neuro checks not being done per order. During an interview on 06/07/24 at 10:20 AM, Resident #6's RP 2 revealed on Friday [03/22/24] Resident #6 had weakness in her hands because she was not able to hold a cup of V8 in order to drink it. They revealed they reported this to LVN A. She further revealed the facility said she was fine so Resident #6's RP 2 let it go. Residents #6's RP 2 continued to reveal the next day on Saturday [03/23/24], Resident #6 speech got worse and Resident #6's balance was off. Resident #6's RP 2 revealed she asked resident to be sent out to the hospital because Resident #6 was not at baseline and got worse. She further revealed the facility called regular transport to send out resident. Record Review of Resident #6's hospital record with admitted [DATE] revealed history of CVA and dysphagia s/p cerebral infarction. [Resident #6] present with slurring in speech that started yesterday at 1 PM, as well as clumsiness and weakness in her left upper extremity that was noted when she attempts to hold objects like a cup. Hospital records further reflected a new diagnosis and chief complaint of cerebrovascular accident (CVA). During an interview on 06/07/24 at 12:41 PM, the DON revealed LVN A reported to her that the family declined having Resident #6's vital signs checked overnight and wanted to wait and see if Resident #6 would get better. During an interview on 06/07/24 at 01:17 PM, LVN A revealed Resident #6 had stroke like symptoms on 03/22/24, but family declined having Resident #6 sent out to the hospital. LVN A further revealed the family wanted LVN A to contact Resident #6's NP to see what she recommended. LVN A revealed NP ordered neuro checks every 4 hours for 3 days. LVN A revealed Resident #6's family declined having neuro checks done when Resident #6 was asleep. LVN A further revealed she did not contact NP B that neuro checks were not done. LVN A also revealed she did not explain what could happen if Resident #6 had a stroke because Resident #6 had a history of having a stroke, so the family knew information about strokes. Left voicemail for LVN C on 06/07/24 at 05:21 PM. During an interview on 06/07/24 at 05:02 PM the DON revealed NP B was not contacted because there were no deficits in neuro checks, which was how the doctor order read. The DON revealed the NP B would not have been contacted if the family refused neuro checks. During an interview on 06/07/2024 at 05:29 PM NP B stated LVN A reported on 03/22/2024 Resident #6 had a change of condition, with weakness in arms and NP B issued an order for Neurological assessments every 4 hours for 3 days. NP B stated she was not aware the orders for Resident #6 Neurological assessments were not performed for 12 hours and would have wanted to be notified when her orders were not followed. NP B stated neurological assessment deficits would indicate a potential for a stroke. NP B stated if the neurological assessment deficit were revealed it would have warranted an immediate hospitalization . During an interview on 06/09/24 at 03:16 PM, the Medical Director stated he was given a report for Resident #6's missed neurological assessments from 03/23/2024 on 06/08/2024. The Medical Director confirmed he did not know about these missed neurological assessments before 06/08/24. He stated the ideal would be for the prescriber to be given a report when the orders given were not able to be completed. Record Review of facility's policy, revised April 2009, Change in a Resident's Condition or Status, reflected 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: f. refusal of treatment or medications. An Immediate Jeopardy (IJ) was identified on 06/07/2024 at 09:00 PM and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 06/08/2024 01:46 PM. Immediate Jeopardy Plan of Removal Verification 6/8/2024 All residents with orders for neuro checks are at risk of the orders not being followed or prescriber not being notified of the refusals. During an interview on 06/08/24 at 02:30 PM, the Administrator revealed the census was 79 and there were 0 residents currently being assessed for neurological assessments. Action to correct and remove IJ: 1.) Verify that current orders are being followed as prescribed by physician/NP. The DON and/or designee will complete this by noon 6/8/2024. During an interview on 06/09/24 at 12:22 PM, the DON stated she and her staff reviewed all the current residents' physicians' orders for compliance and all evidenced compliant. During an interview on 06/08/24 at 02:30 PM, the Administrator revealed there were no residents on neuro checks and 2 residents had received neurological assessments in the recent past, Resident #44 and Resident #48. During an interview on 06/09/24 at 12:22 PM, the DON stated 2 residents (Resident #44 and Resident #48) had received neurological assessments per post fall protocols. The DON stated there were no residents ordered to receive neurological assessments since 03/23/2024 when Resident #6 was ordered neurological assessments due to her stroke-like symptoms. A record review of the facility's census revealed 2 of 79 residents (Resident #44 and Resident #48) had completed worksheets for neurological assessments: o A record review of Resident #44's neurological assessment worksheet dated 05/21/2024, revealed Resident #44 was assessed every 15 minutes 5 times, assessed every 30 minutes 4 times, assessed every hour three times, and every 4 hours 4 times. o A record review of Resident #48's neurological assessment worksheet dated 05/21/2024, revealed Resident #44 was assessed every 15 minutes 7 times, assessed every hour eight times. 2.) All licensed nurses will be in-serviced regarding the need to notify physician/NP of any refusals that keep us from following orders prescribed. The DON and/or designee will complete in-service with team by 6/9/2024. Licensed Nurses on vacation, leave, or unavailable will be trained prior to their next scheduled shift. A Licensed Nurse roster is being utilized to track the Licensed Nurses who have responded and have been in-serviced. The identified Licensed Nurses who are unavailable will attempt to be reached by phone call, text message, and email by DON/Designee. DON/Designee will work with the scheduler and audit daily to ensure any Licensed Nurse will not be scheduled until the necessary in-service has occurred. During an interview on 06/08/24 at 03:02 PM, the DON provided documents titled in-service education attendance record, dated 06/07/24, and facility policy's Change in a Resident's Condition or Status, revised November 2010, and Refusal of Medications and Treatments, Documentation of, revised April 2009. The DON revealed licensed nurses could not work a shift until they have received in-services for following orders and reporting orders that could not be performed and have been sent an email to go to her office to be educated before working a shift. A record review of the facility's nursing roster revealed 23 / 34 licensed nurses were employed. 19 licensed nurses were full time, and 15 licensed nurses were part time. A record review of the facility's nursing roster and schedule revealed 13 nurses worked the 07:00 AM shift to 07:00 PM shift and 10 worked the 07:00 PM to 07:00 PM shift. A record review of the facility's in-service titled Change of Condition; refusal of treatment . dated 06/07/2024, revealed 23 Nurses received the in-service. Interviews: 07:00 AM to 07:00 PM shift: 7 Of 14 nurses, 50%, who worked the 07:00 AM to 07:00 PM shift were interviewed. A sample of the interviews follow: During an interview on 06/09/24 at 10:53 AM, LVN J revealed he received training on reporting to MD or NP if the resident's doctor's orders were not being fulfilled. During an interview on 06/09/24 at 10:59 AM, ADON D and LVN E revealed they were trained in contacting a resident's MD or NP if they were not able to fulfill doctor's orders. They further revealed they could make person centered changes to help fulfill their orders. During an interview on 06/09/24 at 11:10 AM, RN F, RN G, and LVN H not able to carry out a doctor's order they will notify the doctor or NP. RN gave examples of some doctor's orders that need to be followed. During an interview on 06/09/24 at 02:22 PM, the DON revealed she was in-serviced on change of condition policy and refusal of treatment/medication by the COO. Interviews: 07:00 PM to 07:00 AM shift: 6 of 9 licensed nurses, 67%, who regularly worked the 07:00 PM to 07:00 AM shift were interviewed. A sample of the interviews follow: During an interview on 06/09/24 at 10:59 AM, LVN I revealed she was trained in contacting a resident's MD or NP if they were not able to fulfill doctor's orders. They further revealed they could make person centered changes to help fulfill their orders. During an interview on 06/09/24 at 12:22 PM, DON revealed LVN C (who regularly worked 6 PM- 6 AM) could not be contacted to be in-serviced. LVN C had been taken off the schedule until she was able to be in-serviced. During an interview on 06/09/24 at 01:28 PM, LVN K revealed she was educated recently to follow doctor's orders and report to doctor or NP if a resident was not able to receive a treatment or medication. During an interview on 06/09/24 at 01:43 PM, LVN L revealed she was in-serviced on how to complete a change in condition assessment and notify doctor if any doctor's orders were not fulfilled. During an interview on 06/09/24 at 01:55 PM, LVN M revealed she was educated recently to follow doctor's orders and contact MD or NP if an order was not fulfilled. During an interview on 06/09/24 at 02:01 PM, LVN N revealed she would contact the doctor if a resident refused treatment, refused medication, or had a change in condition. During an interview on 06/09/24 at 02:09 PM, LVN O revealed he was trained to contact the doctor if medications or treatments were not fulfilled. 3.) Physicians/NP partners will be notified to provide team with more concise orders and to consider the nurse's feedback regarding specific resident's characteristics or preferences when deciding a plan of action. The communication with our physician partners will be completed by 6/10/2024. During a joint interview on 06/09/2024 at 11:00 AM the Administrator and the DON stated the facility has partnered with all facility medical providers to have a consensus to develop and implement improved physicians' orders to better reflect residents needs and preferences i.e., may assess while awake, may reattempt x3, and please report to physicians after 2x refusals. the Administrator and the DON stated the facility has sent emails to the medical director and all supporting and attending physicians and nurse practitioners. The Administrator stated the facility held an AD-HOC QAPI meeting to review the Plan of Removal. During an interview on 06/09/2024 at 03:18 PM the Medical Director stated the facility informed him of the immediate jeopardy on 06/08/2024 and the facility held an AD-HOC QAPI meeting to review the immediate jeopardy and develop a plan of removal. The medical Director stated he was given a report for resident #6's missed neurological assessments from 03/23/2024 on 06/08/2023. The Medical Director stated the ideal would be for the prescriber to be given a report when the orders given were not able to be completed. 4.) The DON/Designee will review 24-hour report daily for change of condition UDA including neurological checks for any refusals and review for medical provider notification. The Weekend Nurse Manager/Designee will review any refusals and contact DON/Designee if a resident has a refusal to ensure the medical provider has been notified. Audits will be completed daily x14 days, weekly x4 weeks, monthly x3 months, and periodically thereafter. During a joint interview on 06/09/2024 at 11:00 AM the administrator and the DON stated the facility would daily monitor the 24-hour reports for any changes of condition, to include neurological assessments, refusals of any assessments, treatments and or orders: and follow up documentation with reports to physicians. The Administrator and the DON stated the monitoring will be conducted for 14 days, then 4 weeks, and then for 3 months. Record review of Daily Neurological Checks dated 6/8/2024, 6/9/2024 No new neurological checks, created by DON. The Daily Neurological Checks, included Resident name, Date, Notification to family, notification of MD, refusals of vital signs, notification of neurological assessments, Is this care planned and comments sections. Record review of Weekly Neurological Checks blank sheet, includes resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections. Record review of Monthly Neurological Checks Monthly blank sheet, includes resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections. Record review of E-Interact Daily Change of Condition Assessment, dated 6/8/2024 and 6/9/2024. This included resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections. Record review of Daily 24 hour report, dated 6/8/2024, 6/9/2024 revealed no neurological checks for residents. Record review of Weekly 24 hour report, for weekly monitoring blank, included resident name, date, progress note refusals EMR refusals, order note refusals, Is this care planned and comments section. 5.) All residents have the potential to be affected by this alleged deficit practice. At risk resident will be identified by reviewing 24 hr. report, (for) changes of condition assessment and neurological checks. A record review of the facility's unit 6's Nurses station 24-hr report revealed no residents were followed for a change of condition and no residents had refused any treatments. Reviews: (Monitoring) 1.) Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with DON weekly to audit and verify this review has been completed. This will be ongoing for the next two months. 2.) Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis. Record review of QAPI Performance for Improvement instructor, Administrator dated 6/8/202 from 9 AM -10 AM. Subject: Notify of Changes. The QUAPI in-service included the Administrator, DON, CDM, Admissions, Business Manager, Maintenance, Housekeeping, ADON, Activity Director, Social Worker, Human Resources and Medical Director. System of Concerns: In-service on Notification of Changes. Concerning IJ F580 Notify of Changes. 3.) A corporate designee will audit compliance with orders weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body. During an interview on 06/09/2024 at 03:14 PM the Administrator stated the facility's Chief Operating Officer would have oversight and monitoring the facility's Plan of Removal for the following six months. The Administrator and the DON was informed the Immediate Jeopardy was removed on 06/09/24 at 04:07 PM. The facility remained out of compliance at a severity level of potential harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

26869 42402 Based on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. The facility failed to ensure Resident # 6 was assessed as ordered for neuro-checks every 4 hours x 3 days. Resident # 6 was sent to hospital and returned to the facility on [DATE] with new diagnoses to include: cerebral infarction and hemiparesis following cerebral infarction affecting right dominant side, and slurred speech. An Immediate Jeopardy was identified on 6/29/2024 . The IJ template was provided to the facility on [DATE] . While the IJ was removed on 6/30/2024, the facility remained out of compliance at a scope of pattern and a severity level lowered to no actual harm that is not Immediate Jeaperdy due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. This failure could result in assessments not being completed as ordered could result in residents' not receiving the necessary care resulting in a decline in health and or death. This could affect all resident with assistive devices and could result in no orders for resident care. The findings included: Record review of Resident #6's admission record, accessed 06/07/24, reflected the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and dementia (neurodegenerative disease that affects memory, thinking and interferes with daily life). It further reflected Resident #6 returned to the facility on [DATE] with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech. Record Review of nursing progress note, authored by LVN A on 03/22/24 at 1:20 PM, reflected Resident #6's RP reported Resident #6 could not hold her beverage. This progress notes further revealed NP B ordered neuro checks Q 4 hrs x 3days, and to notify NP of any deficit. Record Review revealed Neuro-checks were not started until 4:00 pm. Record review of Orders- Administration Note , authored by LVN C, reflected: 03/23/24 at 02:02 AM Neuro check was not done due to [Resident #6] being asleep. 03/23/24 at 04:55 AM Neuro check was not done due to[family member] refusal. Record review of Orders- Administration Note , authored by LVN A, reflected: 03/23/24 at 09:06 AM Neuro check was not done due to family member refused since [Resident #6] was sleeping. Record review of nursing notes from 03/23/24 revealed no documentation of NP or MD being notified of neuro checks not being done per order. During an interview on 6/25/2024 at 6:35 pm LVN A revealed she did not explain what could happen if Resident #6 had a stroke to the family, because Resident #6 had a history of having a stroke, so the family knew information about strokes. LVN A said when the resident/family refused neuro checks she did not go back and attempt to reassess the resident until the next 4-hour interval. During an interview on 6/25/2024 at 6:49 pm, LVN C stated Resident #6's family member did not allow her to do one of the neuro checks (12 midnight) 3/23/2024 the resident was sleeping. The Resident refused neuro checks at 4:00 am. LVN C further revealed she did not contact NP B when neuro checks were not done. LVN C also revealed she did not explain what could happen if Resident #6 had a stroke because Resident #6 had a history of having a stroke.LVN C said when the resident/family refused neuro checks she did not go back and attempt to reassess the resident until the next 4-hour interval. She further revealed she tried once, and the resident hit me. The resident said leave me alone. During a telephone interview on 6/28/2024 at 12:30 pm NP B stated she remembers the nurses calling her in March 2024 regarding stroke like symptoms, she doesn't recall the specifics, but she feels they let her know how the resident was based on their long-time knowledge of the resident. The nurses once they found the resident to have a change sent her to the hospital. She stated based on the statements of the nurses was how she was sent to the hospital. Resident #6 was admitted to hospital on 3/23/24 and diagnosed with: cerebral infarction and hemiparesis following cerebral infarction affecting right dominant side, and slurred speech. The plan of removal was submitted by the facility and was accepted on 06/29/24 at 10:07 AM. It was documented as follows: Action to correct and remove IJ: 1.) Verify that all assessments were being followed as ordered by physician/NP. The DON and/or designee will complete this by noon 06/29/24. 2.) All licensed nurses will be in-serviced regarding the need to notify physician/NP immediately of any refusals that keep us from following physician ordered assessments. The DON and/or designee will complete an in-service with the team by 06/30/24. Licensed Nurses on vacation, leave, or unavailable will be trained prior to their next scheduled shift. A Licensed Nurse roster is being utilized to track the Licensed Nurses who have responded and have been in-serviced. The identified Licensed Nurses who were unavailable will attempt to be reached by phone call, text message, and email by the DON/Designee. The DON/Designee will work with the scheduler and audit daily to ensure any Licensed Nurse will not be scheduled until the necessary in-service has occurred. 3.) The DON/Designee will review 24-hour report daily for change of condition UDA (Unified Defined Assessment-a change of condition assessment) including neurological checks for any refusals and review for medical provider notification. The Weekend Nurse Manager/Designee will review any refusals and contact the DON/Designee immediately if a resident has a refusal to ensure the medical provider has been notified. Audits will be completed daily x14 days, weekly x4 weeks, monthly x3 months, and periodically thereafter. 4.) All residents have the potential to be affected by this alleged deficient practice. At risk residents will be identified by reviewing 24-hour report, changes of condition assessment and neurological checks. Reviews: 1.) Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with the DON weekly to audit and verify this review has been completed. This will be ongoing for the next two months. 2.) Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis. 3.) A corporate designee will audit compliance with orders weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body. The facility's POR verification was as follows: In an interview on 06/29/24 at 12:53 PM the DON stated all but 1 of the 24 nurses had been in-serviced to notify the physician immediately if a resident refused an assessment and the 1 nurse who had not been in-serviced would not be scheduled until they received the in-service. Interviews on 06/29/24 from 12:05 PM to 4:05 PM with 8 nurses (3 RNs and 5 LVNs), five of whom worked the day shift (6 AM to 6 PM) and three of whom worked the night shift (6 PM to 6 AM), revealed they were in-serviced to immediately notify the resident's physician/NP if a resident refused to have an assessment completed, to document the resident refused the assessment in the nurse's progress notes and the physician was notified, and to notify the resident's responsible party. In an interview on 06/29/24 at 4:01 PM, the DON stated she had printed out all the physician orders and verified the assessments had been completed. In a further interview on 06/29/24 at 4:20 PM, the DON stated there was only one resident who had orders for neurological checks that were initiated on 06/28/24 and completed 06/29/24 and the resident did not refuse the neurological assessments. In an interview on 06/29/24 at 4:52 PM the DON stated she would review the 24-hour reports, the orders in the EHR, and the change of condition reports daily for notation of change of condition in a resident. The DON stated the Weekend Supervisor and the ADON would continue the monitoring when she was not in the facility. The DON stated an ad hoc QAPI meeting was held on 06/28/24 with the Medical Director and department heads in reference to the IJ for not completing an ordered assessment. The DON stated the Chief Operating Officer would conduct weekly audits of the facility's monitoring of compliance with ordered assessments. In an interview on 06/29/24 at 5:09 PM the Administrator stated she reviewed the 24-hour reports with the DON for ordered assessments. The DON in-serviced the nurses on ensuring ordered assessments were completed and to notify the physician immediately if an assessment was refused by the resident. The Administrator stated they would obtain daily the 24-hours reports from the EHR to monitor ordered assessments. The Administrator said an ad hoc QAPI meeting was held on 06/28/24 and not notifying the physician when a resident refused an assessment was reviewed and discussed. The Medical Director, the DON, the ADON and other department heads were present at the ad hoc QAPI meeting. The Administrator stated the Chief Operating Officer would conduct the weekly audits of compliance with monitoring physician order assessments. Record review of an undated, untitled list of nurses revealed 24 nurses were employed at the facility. Record review of the In-Service Education Attendance Record dated 06/28/24, for Completing assessments as ordered per physician/NP, revealed 23 nurses had been in-serviced. Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for reviews of the 24-Hour report. The 24-Hour Report monitoring form had columns for the resident's name, date, progress notes refusals, EMH refusals, order note refusals, and if it was care planned. Record review of the facility's POR verification binder revealed on the 24-Hour Report daily monitoring sheets revealed on the first row was handwritten 06/29/24 no refusals (i.e., no refusal of care/medications/assessments). On the second row was handwritten a resident's name, date of 06/30/24, notation the resident refused a medication, it was care planned the resident would refuse the medication, and the physician was informed. Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for reviews of the E-Interact Change of Condition Assessment. The E-Interact Change of Condition Assessment monitoring form had columns for the resident's name, date, notification to family, notification to the physician, notification of refusal of treatment, notification of refusal of meds, and if it was care planned. Record review of the Daily E-Interact Change of Condition Assessment form revealed residents who had a change of condition on 06/28/24 and 06/29/24 were listed, all the resident's physicians and RP's were notified and none of the residents refused care or assessments. Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for Neurological Checks audits. The Neurological Checks monitoring form had columns for the resident's name, date, notification to family, notification to the physician, refusals of vital signs, notification of neurological assessments, and if it was care planned. Record review of the Order Listing Report, dated 06/29/24, revealed there was only 1 resident with orders for neurological checks to be completed in a 24-hour period. In an interview on 06/29/24 at 4:20 PM, the DON stated there was 1 resident who had orders for neurological checks and there was another resident who had a fall on 06/28/24 that neurological checks were being done on. Both residents were listed on the Daily Neurological Checks monitoring sheet. Record review of the Daily Neurological Checks monitoring sheet revealed 2 residents were listed on 06/28/24 for neurological checks, their physician's and RP's were notified, and the residents did not refuse the assessment. On 06/29/24 there were no residents with orders for neurological checks. Record review of an In-Service Education Attendance Record, dated 06/28/24, revealed an ad hoc QAPI meeting was held at 6 PM to discuss assessment documentation and all assessments were not being completed as ordered could result in residents not receiving the necessary care resulting in a decline in their health or even death. The meeting was conducted by the Administrator and in attendance were the Medical Director, the Activity Director, the ADON, the DON, the BOM, the dietitian, and the housekeeping director. An Immediate Jeopardy was identified on 6/29/2024 . The IJ template was provided to the facility on [DATE] . While the IJ was removed on 6/30/2024, the facility remained out of compliance at a scope of pattern and a severity level lowered to no actual harm that is not Immediate Jeaperdy due to the facility's need to monitor and evaluate the effectiveness of the corrective actions.

Based on observations, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. There were approximately 5 boxes that appeared to be less than 18 inches from the ceiling, in the walk-in fridge. 2. There was a chocolate pie that was not fully covered in the walk-in fridge. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During observations and an interview in the initial tour of the kitchen with the CDM on 06/04/24 at 09:02 AM, there were approximately 5 cardboard boxes filled with various food products that appeared to be less than 18 inches from the ceiling, in the walk-in refrigerator. It was also observed there were 2 chocolate pies that were not completely wrapped, and their pie crusts were exposed. The CDM revealed the boxes should not be stored this close to the ceiling and the chocolate pies will be thrown away because she would not be able to serve these food products now. The CDM was not able to identify who could have done this, but the staff were trained on covering food products appropriately for storage and items should be stored more than 18 inches away from the ceiling. Record review of the facility's policy Food storage, revised 02/23/24, reflected All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption., Cover label and date unused portions and open packages., and Store items 6 inches above the floor and 18 inches below sprinklers.

Based on interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 3 of 9 residents (confidential residents in group) reviewed for frequency of meals. The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Findings included: Record review of the resident snack list (undated), was provided by the DM. There were 4 residents that received three times a day, to include HS snacks. The snack list provided by the DM were residents that had dialysis. There was no resident list with HS snacks provided. Record review of the resident roster dated 6/4/2024 reflected a census of 79 residents. Record review of the posted Meal Service Times in the dining room revealed the following: Breakfast - 7:20 -8:00 AM Lunch - 11:35-12:00 AM Evening meal - 4:20 -5:00 PM- There is no posting to advise any resident a snack or availability of type of snack after specified times. During interview on 6/6/2024 at 1: 00 PM with residents in group of 9 residents, it was brought to the attention of the state surveyors that they have not been made aware of options of a snack which were available to residents. Residents said they were not offered any HS snacks by staff. During interview on 6/6/2024 at 2:29 PM with Restorative Aide/CNA R stated she worked (7-3:30pm) stated there was a snack box in the nursing station refrigerator. During interview on 6/6/2024 at 4:17 PM with LVN Q stated she worked 6AM-6PM. LVN Q stated resident came to staff if they wanted some snacks, such as cookies, chips, sandwiches. LVN Q stated the diabetic resident were able to have snacks for the nursing refrigerator that were low in sugar. During interview on 6/06/2024 at 6:15 PM with CNA S stated she worked for 31 yrs., on the 6PM-6AM shift. CNA S stated she provided HS snacks to residents if they asked her. CNA S stated she did not go around and offer residents a snack. During interview on 6/6/2024 at 6:29 PM CNA T stated she worked for 1 year at the in facility. CNA T stated there were resident snacks in the refrigerator behind the nurse's station . CNA T stated she had not offered HS snacks to every resident, only if residents asked her. During interview on 6/6/2024 at 6:33 PM the CDM, director of culinary services, stated she only had a dialysis snack list. CDM stated no other snacks go out from the kitchen. During interview on 6/6/2024 at 6:35 PM with the DM stated they place resident snacks in the nursing station refrigerator. During interview on 6/7/2024 at 11:32 AM with the ADM stated snacks were offered at bedtime to residents, nursing department and anytime a resident request a snack. The ADM stated the bedtime snacks were offered after dinner. The ADM stated if resident were not offered snacks, resident will be hungry and diabetic residents could have an effect on their blood sugars. The ADM stated resident can ask for snacks and nursing department can provided snacks. The ADM stated the Activities department had snacks when they have functions throughout the day. No other response. Record Review of the Facility Policies and Procedures for Resident Food Services dated 5/95 revealed, SNACKS- Procedures: Nursing offers bedtime snacks.

Based on observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 16 (#6 , #3, #38, #56, #57, #120) in that: 1. Resident #6 received honey consistency liquids instead of nectar thick liquids. 2. Resident #3 did not have her 1/4 bed [NAME] in her care plan. 2. Resident #38 did not have her indwelling catheter in her care plan. 3. Resident #57 did not have her 1/4 bed rails in her care plan. 4. Resident #120 did not have her 1/4 bed rails in her care plan. 5. Resident #56 did not have his dentures mentioned in his care plan. The facility failed to ensure Resident #6's care plan was comprehensive and updated to reflect Resident #2's doctor's order of needing honey consistency liquids instead of nectar thick liquids. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The Findings were: Record review of Resident #6's admission record dated 6/7/2024 revealed a male was admitted on [DATE] with diagnoses that included dementia (loss of thinking, remembering, and reasoning skills), personal history of traumatic brain injury, dysphagia (a condition with difficulty in swallowing food or liquid), cognitive communication deficit, and muscle wasting and atrophy. Record review of Resident #6's annual MDS, dated [DATE], reflected Resident #6's BIMS score was 99, indicating resident was not able to complete the interview with short term and long-term memory problems and severely impaired cognitive skills for daily decision making. It further reflected Resident #6 was severely impaired-never/rarely made decisions. The MDS also indicated Resident #6 was on a mechanically altered diet, requiring change in texture of food or liquids. Record review of Resident #6's care plan, accessed 05/23/24, reflected [Resident #2] has potential nutrition problem r/t mechanically altered diet, revised on 03/06/2024, with an intervention of Administer Nectar thick liquid as ordered., initiated 11/30/2021 with no revision date. Record Review of Resident #6's Doctor's diet orders reflected honey consistency liquids since 08/30/22. 1. Record review of Resident #3's Admission Record dated 6/7/2024 revealed she was admitted on [DATE], age 91 with diagnoses of polyneuropathy, heart failure, cognitive communication deficit, and dementia. Record review of Resident #3's consolidated physician's order 5/16/2023-TRANSFER ASSISTIVE DEVICE: X2, 1/4 rails up as per Dr's order while in bed, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury. Record review of Resident #3's Quarterly MDS dated [DATE] revealed she had a BIMs of 2/15 (severely cognitively impaired), she used a wheelchair to mobilize, she was maximum assistance with transfers. Record review of Resident #3's care plan dated 5/6/2024 revealed no care plan to address the 1/4 side rails. Record review of Resident #3's Transfer Assist Device Assessment form dated 5/16/2023 revealed a recommendation of bilateral 1/4 [NAME]. Interview on 6/6/2024 at 4:10 PM LVN Q stated she just changed her bed on Monday of this week. 2. Record review of Resident #38's Admission Record dated 6/7/2024, age 99 revealed she was admitted on [DATE] with diagnoses of altered mental status, acute kidney failure, cognitive communications deficit, dementia and retentions of urine. Record review of #38's consolidated physician orders for June 2024 revealed she had an order for indwelling catheter with diagnoses of urine retention. Record review of Resident #38's Quarterly MDS dated [DATE] revealed her BIMS was 99, with short/long-term memory, she used a wheelchair to mobilize, she was dependent with toileting, and had an indwelling catheter. Record review of Resident #38's care plan dated 3/28/2024 revealed she had an indwelling catheter for neurogenic bladder but had no interventions. Observation on 6/5/2024 at 11:40 AM revealed Resident # 38 was in the dining room eating by herself. The indwelling catheter bag was under the wheelchair and had privacy bag. Interview on 6/6/2024 at 6:18 PM with the DON revealed Resident #38 did not have interventions for her indwelling catheter. The DON stated the nursing department, nurse manager (DON, ADON) did the care plans for nursing section in resident care areas. The DON stated the resident interventions were to monitor for quinks, care, size, nursing staff would benefit from seeing care plan. The DON stated nurses look at the care plan for catheters. 3. Record review of Resident #57's Admission Record dated 6/7/2024, age 101 revealed he had a diagnosis of diabetes II, need for assistance with personal care, and history of falls. Record review of Resident #57's Quarterly MDS dated [DATE] revealed her BIMS score was 6/15 (severe cognitive impairment), used a manual wheelchair, and max assist with transfers. Record review of Resident #57's care plan dated 6/3/2024 revealed no care plan for 1/4 bed rails. Record review of Resident #57's Transfer Assist Device Assessment form dated 5/17/2023 revealed a recommendation of bilateral 1/4 [NAME]. Observation on 6/5/2024 at 11:30 AM revealed Resident #57 had 1/4 hand [NAME] in her bed. Resident # 57 was not in the room. Observation on 6/5/2024 at 3:34 PM revealed two 1/4 handrails on Resident #57's bed. Observation of Resident #57 w as sitting in her wheelchair. 4. Record review of Resident #120's Admission Record dated 6/7/2024 revealed she was admitted on [DATE], age 65 with a diagnoses of end stage renal disease, diabetes II, abnormal gait/mobility and heart failure. Record review of Resident #120's consolidated physician orders for June 2024 revealed an order for 5/20/2024-TRANSFER ASSISTIVE DEVICE: X2, 1/4 rails up as per physician order while in bed, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury. Record review of Resident #120's Admission MDS dated [DATE] revealed she was BIMS 15/15 (cognitively intact), mobilized in wheelchair, impairment on one side of lower extremity, and roll left and right required partial/moderate assistance. Record review of Resident #120's care plan dated 5/13/2024 revealed no care plan for 1/4 bed rails. Record review of Resident #120's Transfer Assist Device assessment dated [DATE] recommendation left and right 1/4 side rails. Observation on 6/4/20/24 at 11:29 AM revealed Resident #120 was in bed and had two 1/4 side rails on each side of her bed. Interview on 6/7/2024 at 11:50 AM with the ADM stated the 1/4 bed rails risk would be staff does not know the rails were in place. No other response. 5. Record review of Resident #56's Admission Record dated 6/9/2024 revealed he was admitted on [DATE], age 89 with diagnoses of alcoholic cirrhosis of liver (impaired liver function caused by formation of scar tissue) and major depressive disorder. Record review of Resident #56's Quarterly MDS dated [DATE] revealed he had a BIMS of 8/15 (moderately cognitively impaired) and nothing noted in Section L- Oral/Dental Status. Record review of Resident #56's care plan, undated, revealed no mention of dentures. During an interview on 06/06/24 at 02:00 PM, Resident #56's RP revealed Resident #56 had been going to the dentist recently to get his dentures fixed. During an interview on 06/06/24 at 01:47 PM, Resident #56's dentist revealed she was seeing Resident #56 to repair his dentures. During an interview on 06/07/24 at 12:13 PM, the DON revealed dentures should be care planned so the CNAs know what to do for the resident's care when it comes to oral care. During an interview on 05/24/24 at 11:19 AM, Speech Therapist C (ST C) revealed if a resident was determined to need honey thickened liquids and received nectar thickened liquids there could be a chance of aspiration where a solid or liquids could get into the airways. She further revealed this could lead to aspiration pneumonia which could cause a resident to be hospitalized . She revealed if a resident was more compromised there could be more severe health consequences, including death. ST C revealed there had been times where a resident may refuse a liquid if they knew they could not tolerate it, which could cause dehydration. She further revealed she had not heard of a resident at this facility complaining about this scenario, however, you may not be able to know this if a resident was nonverbal. During an interview on 05/24/24 at 03:23 PM, the RD revealed the facility was giving resident honey thickened liquids. She further revealed CNAs were providing liquids to Resident #2 in between meals but would have to ask the DON how the CNAs knew what liquids to give Resident #2. During an interview on 05/24/24 03:54 PM, MDS nurse P and MDS nurse Q stated CNAs followed tasks that were developed from care plans. MDS nurse P confirmed Resident #2's care plan reflected an intervention of Administer Nectar thickened liquid as ordered. She further confirmed this would turn into a task on their POC dashboard for the CNAs to follow. MDS nurse Q confirmed Resident #2's POC Shift Dashboard record, accessed on 05/24/24 at 11:01 AM, revealed there was a directive to give Resident #2 Nectar Thick Liquids. MDS nurse P and MDS nurse Q revealed if resident was receiving Nectar thickened liquids and needed honey thickened liquids, this could cause aspiration. Left VM for doctor and NP on 05/24/24 at 3:20 PM. During an interview on 5/30/24 at 02:33 PM, the administrator and the DON revealed nursing staff received liquids from the kitchen, which would be honey thickened liquids. If the kitchen did not give these liquids, the DON would get involved and ensure the correct liquid was given. Record review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, revised March 2022, reflected, 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record review of the facility policy dated 4/6/2009 revealed The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care of services to the resident. Record Review of POC Shift Dashboard and interview with CNA D, dated 05/24/24 at 11:01 AM, reflected Resident #2 received NUTRITION- Fluids: NECTAR THICK LIQUIDS QShift. CNA D revealed she was following this directive and giving Resident #2 Nectar thickened liquids. There were no observations of Resident #2 receiving nectar thickened liquids. Meals and snacks included honey thickened liquids. 48366

Based on observations, interviews and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 1 of 8 residents (Resident #6) reviewed for food and nutrition services. The facility failed to ensure Resident #6 had a physician's order for a pureed diet with nectar thickened liquids. The resident was prescribed a pureed diet with thin liquids and was provided a pureed diet with nectar thickened liquids. This deficient practice could place residents who are provided a modified texture diet at risk poor intake, and weight loss and diminished quality of life. The findings were: Record review of Resident #6's admission record, accessed 06/07/24, revealed the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and mild protein-calorie malnutrition. Record review of Resident #6's significant change in status MDS, dated [DATE], reflected a BIMS score of 99, indicating resident was unable to complete the interview. Further review of this MDS reflected Resident #6's cognitive skills for daily decision making was severely impaired with short term and long-term memory problems. Resident #6's MDS assessment further revealed resident was on a mechanically altered diet- require change in texture of food or liquids while a resident. Record review of Resident #6's physician's orders for May 2024 revealed the following diet order: Special Diet: REGULAR diet Consistency: PUREED texture, Liquid: THIN consistency with an order date of 04/01/2024. Record review of Resident #6's comprehensive person-centered care plan, undated, revealed the following focus area: [Resident #6] has swallowing problems r/t cerebral infarction, dysphagia with interventions to include Special diet: REGULAR diet, Consistency: PUREED texture, Liquid: THIN consistency, initiated 04/01/2024. Record Review of Resident #6's weight loss history revealed no weight loss since 04/01/2024. During an interview on 06/04/24 at 12:10 PM and record review of Resident #6's lunch meal ticket revealed it stated: DIET: Pureed, *Regular, Nectar, Resident #6's RP 1 revealed there was a nectar thickener packet on Resident #6's lunch meal tray and they had to add it to the V8 to make it nectar thickened. Resident #6's RP 1 further revealed she was unaware of the nursing staff thickened the liquids, because it has been their job to thicken the liquids for their mom. During an interview on 06/04/24 at 12:19 PM, LVN U revealed Resident #6 should have nectar thickened liquids, according to her meal tray ticket. He further revealed the kitchen was supposed to thicken her fluids to be nectar thickened. During an interview on 06/05/24 at 10:33 AM, Resident #6's RP 2 revealed the family comes to lunch with Resident #6 and had to thicken Resident #6's liquids to nectar consistency. This family member was able to describe the process of thickening Resident #6's liquids. It was later observed that Resident #6 received a nectar thickening packet on her 06/05/24 lunch meal tray ticket to thicken the liquids on her tray ticket. During a combined interview on 06/06/24 at 10:52 AM, the RD revealed Resident #6's family requested for Resident #6 to have nectar thickened liquids. She further revealed she was allowed to downgrade diets from thin to nectar thickened liquids on Point Click Care and meal tray cards. The CDM revealed the kitchen did not thicken liquids to the nectar consistency, because by the time they would get to the resident, the liquids that were thickened in the kitchen would be too thickened and hard to drink. The CDM further revealed the trays that need to have liquids thickened to nectar consistency were sent with packets of thickening agents for the nursing staff to add to liquid when they put the residents' trays down. They both revealed residents needed to have the right consistency as a safety precaution to prevent adverse reactions such as coughing or choking. Record review of the facility's policy Thickened liquids, revised 1/24, reflected the following: Thickened liquids will be available for those who have difficulty swallowing thin liquids. Liquids will be thickened to the degree specified in the physician or designee's orders. Physician/designee orders thickened liquids in medical record. Food and Nutrition Department ensures resident nutrition profile is updated with thickened liquid order and provides thickened liquids per community approved diets. Record review of the facility's policy, Physician delegated diet and nutrition orders, revised 01/24, reflected A resident's attending physician may delegate the task of writing diet orders to a qualified dietitian .

Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Resident #54) reviewed for their right to voice grievances to the facility. CNA P failed to report and document Resident #54's complaint she was left without a call light, left unattended, and received rushed care. This failure could place residents at risk for harm by not having their grievances addressed. The findings included: A record review of Resident #54's admission record dated 06/06/2024 revealed an admitted [DATE] with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (a condition where the eye's optic nerve, which provides information to the brain, is damaged and will cause gradual vision loss), atherosclerosis of the aorta (a condition characterized by the gradual buildup of plaque in the largest artery in your body). A record review of Resident #54's annual MDS assessment dated [DATE], revealed Resident #54 was a [AGE] year-old female assessed with an ability to hear as, Moderate difficulty - speaker has to increase volume and speak distinctly, with impaired vision, Impaired - sees large print, but not regular print in newspapers/books, and had clear speech, was attentive, and did not have disorganized thinking. Further review of the assessment revealed Resident #54 had not refused any care provided. Resident #54 was assessed as always incontinent of bowel and bladder. Resident #54 was assessed as, Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity, Or the assistance of 2 or more helpers is required for the resident to complete the activity for the following abilities: Eating, oral hygiene, toileting hygiene, personal hygiene, shower / bathing dressing, and transferring. Manual wheelchair - Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Manual wheelchair, Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. A record review of Resident #54's care plan dated 06/06/2024 revealed, The resident has a potential for communication problem Hearing deficit .The resident will be able to make basic needs known on a daily basis through the review date .Be conscious of resident position when in groups, activities, dining room to promote proper communication with others . Ensure/provide a safe environment: Call light in reach A record review of the facility's grievance report logbook revealed grievances for the last 8 months . A review of the grievances revealed no evidence for a grievance for Resident #54. During an observation and interview on 06/05/2024 at 11:05 AM revealed Resident #54 loudly calling out for attention. Resident #54 was observed seated in her wheelchair in her room positioned mid room equidistant from her bed and the entry door. Resident #54's call light rested upon her bed and out of her reach by an approximate 3 feet. Resident #54 stated she was brought into her room by a CNA and left there without an ability to call for assistance. Resident #54 stated she did not have a call light within her reach. Resident #54 stated she was angry that staff do not take time with their care, (they) rush with care and run off. During an observation and interview on 06/05/2024 at 11:16 AM revealed CNA P entered Resident #54's room responding to Resident #54's loud vocalizations calling out for assistance. Upon CNA P's entrance Resident #54 began with a complaint alleging you left me here .you said you would be right back .I had to yell to get you here . Resident #54 continued in an irritable manner and would often over speak CNA P, .you all are always in a rush and leave CNA P stated she had assisted Resident #54 in her wheelchair to her room and placed Resident #54 where she sat in her wheelchair as observed. CNA P stated Resident #54's call light was on Resident #54's bed and out of reach from Resident #54. CNA P stated she positioned Resident #54 away from her bedside due to Resident #54's preference. CNA P stated she had not attempted to place Resident #54's call light at her side. CNA P then attempted to reposition Resident #54's call light and succeeded to place Resident #54's call light at Resident #54's side, secured to her wheelchair. Resident #54 continued to verbalize irritably, don't tell your stories .you left me here .without lunch .with the button over there CNA P stated she understood Resident #54 had made a complaint and was asked what do you do when a Resident makes a complaint? CNA P stated, I have explained to her (Resident #54) I cannot stay here; I have other work to do. CNA P stated Resident #54 had a desire for someone to stay with her and she could not due to her duties. During an interview on 06/07/2024 at 09:04 AM the DON stated staff should assist residents with a grievance report. During an interview on 06/08/2024 at 02:03 PM the Administrator stated she was unaware of Resident #54's grievance and would look into the event on 06/05/2024 with CNA P and Resident #54. The Administrator stated she would provide a grievance policy. A record review of the facility's Grievances, Resident / Responsible Party policy dated 08/01/2017, revealed, Policy Interpretation and Implementation: A resident has the right to voice grievances without discrimination or reprisal. Grievances include those with respect to treatment which has been furnished as well as that which has not been furnished; and a resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to behavior of other residents. The resident has the right to obtain a written decision regarding his or her grievance. Grievances are not limited to formal written grievances and may also include residents verbalized complaints to facility staff. It is the intent of this facility to make prompt efforts to resolve including facility acknowledgment of complaints grievances. Staff will work actively towards resolution of complaints and grievances

Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents (Resident #54) reviewed for call lights. Resident #54 was placed in her room without access to her call light. On 06/05/2024 CNA P assisted Resident #54 in her wheelchair to her room and placed her out of reach of her call light. This failure could place residents at risk for harm by not having the ability to call for assistance. The findings included: A record review of Resident #54's admission record dated 06/06/2024 revealed an admitted [DATE] with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (a condition where the eye's optic nerve, which provides information to the brain, is damaged and will cause gradual vision loss), atherosclerosis of the aorta (a condition characterized by the gradual buildup of plaque in the largest artery in your body). A record review of Resident #54's annual MDS assessment dated [DATE], revealed Resident #54 was a [AGE] year-old female assessed with an ability to hear as, Moderate difficulty - speaker has to increase volume and speak distinctly, with impaired vision, Impaired - sees large print, but not regular print in newspapers/books, and had clear speech, was attentive, and did not have disorganized thinking. Further review of the assessment revealed Resident #54 had not refused any care provided. Resident #54 was assessed as always incontinent of bowel and bladder. Resident #54 was assessed as, Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity, Or the assistance of 2 or more helpers is required for the resident to complete the activity for the following abilities: Eating, oral hygiene, toileting hygiene, personal hygiene, shower / bathing dressing, and transferring. Manual wheelchair - Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Manual wheelchair, Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. A record review of Resident #54's care plan dated 06/06/2024 revealed, The resident has a potential for communication problem Hearing deficit .The resident will be able to make basic needs known on a daily basis through the review date .Be conscious of resident position when in groups, activities, dining room to promote proper communication with others . Ensure/provide a safe environment: Call light in reach During an observation and interview on 06/05/2024 at 11:05 AM revealed Resident #54 loudly calling out for attention. Resident #54 was observed seated in her wheelchair in her room positioned mid room equidistant from her bed and the entry door. Resident #54's call light rested upon her bed and out of her reach by an approximate 3 feet. Resident #54 stated she was brought into her room by a CNA and left there without an ability to call for assistance. Resident #54 stated she did not have a call light within her reach. Resident #54 stated she was angry that staff do not take time with their care, (they) rush with care and run off. During an observation and interview on 06/05/2024 at 11:16 AM revealed CNA P entered Resident #54's room responding to Resident #54's loud vocalizations calling out for assistance. Upon CNA P's entrance Resident #54 began with a complaint alleging you left me here .you said you would be right back .I had to yell to get you here . Resident #54 continued in an irritable manner and would often over speak CNA P, .you all are always in a rush and leave CNA P stated she had assisted Resident #54 in her wheelchair to her room and placed Resident #54 where she sat in her wheelchair as observed. CNA P stated Resident #54's call light was on Resident #54's bed and out of reach from Resident #54. CNA P stated she positioned Resident #54 away from her bedside due to Resident #54's preference. CNA P stated she had not attempted to place Resident #54's call light at her side. CNA P then attempted to reposition Resident #54's call light and succeeded to place Resident #54's call light at Resident #54's side, secured to her wheelchair. Resident #54 continued to verbalize irritably, don't tell your stories .you left me here .without lunch .with the button over there During an interview on 06/07/2024 at 09:04 AM the DON stated call lights were to be placed within a residents reach. The DON added there maybe times when residents may not be able to be placed next to their call lights, e.g., during activities, when residents have their ability to self-ambulate within their room, and according to their preferences, residents in their room should have their call lights within reach. During an interview on 06/09/2024 at 12:20 PM the DON stated the facility's policy for call lights was to adhere to the CMS regulations regarding call lights . A record review of the CMS's State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities dated 02/03/2023, revealed, GUIDANCE .Reasonable accommodation(s) of resident needs and preferences includes, but is not limited to, individualizing the physical environment of the resident's bedroom and bathroom, as well as individualizing common living areas as much as feasible .PROCEDURES .Observe residents in their rooms and common areas and interview residents, if possible, to determine if their environment accommodates their needs and preferences .Determine if the resident has the call system within reach and is able to use it if desired.

Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 1 of 7 residents (Resident #170) reviewed for pharmacy services. LVN U dispensed Resident #170's medications (11 pills) and stored them in a small pill cup in the medication cart with the intention of administering the medications at a later time and continued to dispense and administer medications for other residents. This failure could place residents at risk for harm by medication administration errors. The findings included: A record review of Resident #170's admission record dated 06/07/2024 revealed an admitted [DATE] with diagnoses which included hypertension (high blood pressure), diabetes type II (a condition where the body's cells cannot readily accept sugars from the blood), hyperlipidemia (a condition where the blood too much fat (lipids)). A record review of Resident #170's admission MDS assessment dated [DATE] revealed Resident #170 was a [AGE] year-old male assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #170's physicians' orders dated 06/07/2024, revealed Resident #170 was prescribed the following medications to be administered daily at 08:00 AM: 1. Amlodipine 5mg (used to trat high blood pressure). 2. Aspirin 81mg (used to prevent heart attacks). 3. Fish oil capsule 1000mg (used for dietary supplement). 4. Lisinopril 40mg (used to treat high blood pressure). 5. Multivitamin (used for a dietary supplement). 6. Sertraline 100mg (used to treat depression). 7. Vitamin C (used as a dietary supplement). 8. Donepezil 10mg (used to treat dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities)). 9. Gabapentin 600mg (used to treat nerve pain). 10. Hydralazine 50mg (used to treat high blood pressure). 11. Sennosides-Docusate Sodium 8.6-50mg (used to treat constipation). During an observation and interview on 06/07/2024 at 08:12 AM revealed LVN U attended her medication cart and was preparing medications for another Resident. Observations of LVN U opening drawers of the medication cart revealed the top drawer had a small clear plastic cup with pills. LVN U stated the cup contained Resident #170's morning medications. LVN U stated she had dispensed Resident #170's medications and attempted to administer Resident #170 his medications and was unable to do so due to Resident #170 was not available and was in the shower. LVN U stated she had stored the loose pills in their pill cup for a later attempt to administer. LVN U stated she then proceeded to dispense and administer medications to other residents. During an observation and interview on 06/07/2024 at 08:20 AM revealed the DON approach the medication cart and inquire of LVN U here status on medication administration and the surveyor reported to the DON that LVN U had Resident #170's medications in a pill cup. The DON inquired of LVN U the nature of the pills in the cup and LVN U reported the pills were dispensed for Resident #170 however Resident #170 was in the shower. The DON stated LVN U should have disposed the medications and would need to re-dispense the medications when Resident #170 became available. During an interview on 06/07/2024 at 0859 AM the DON stated medications should be dispensed and administered prior to dispensing and administering medications for the next Resident. A record review of the facility's policy titled Storage of Medications dated April 2009, revealed, Policy Interpretation and Implementation: Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they were received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner A record review of the American Association of Post-Acute Care Nursing's website: Resident Safety and Nurse Workarounds - AAPACN accessed 06/11/2024, titled, Resident Safety and Nurse Workarounds, revealed, Nurse workarounds defined .Nurse workarounds are actions that nurses take to deliver care and accomplish the work assigned to them, despite those actions' deviating from protocol and policy .workarounds occur in SNFs (Skilled Nursing Facility's) .For example, a nurse who pops medication from a multi-dose card and pre-pours pills or places them in medication cups to be administered later, for one or more residents, does not intend to cause harm. Nurses do this so they can dispense medications quickly, saving precious time and allowing them to move on to the next task they must complete. But the intended time-saver exposes patients to the risk of harm. While an error probably will not occur every time a workaround is used, when one does occur, the harm is likely to be significant

Based on observation, interview and record review, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -RN A failed initiate CPR (cardiopulmonary resuscitation) when determined R #1 was unresponsive as notified by CNA B. -R #1 was left unattended by staff for a period of 4 minutes on [DATE], which resulted in a delay of life saving measures. - Staff did not arrive with the AED and crash cart for a period of 14 minutes, to be used in conjunction with CPR. -R #1 expired at the facility on [DATE]. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and even death. These failures resulted in an IJ on [DATE] at 3:45 PM. While the IJ was removed on [DATE] at 11:30 AM, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope of isolated due to facility's need to evaluate the effectiveness of their plan of removal and complete training. The findings were: Record review of R #1's face sheet, dated [DATE], and EMR (electronic medical record) revealed, the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#1 age 68. Advanced Directive indicated R #1 was a Full Code. RP (responsible party) was listed as: a family member. Record review of Resident #1's 5 Day Medicare MDS, dated [DATE], revealed, o BIMS (brief interview of mental status) Score= 13 (cognitively intact) o ADLs (activities of daily living): B/B (bowel and bladder) supervision one person (continent) Transfer = extensive 2 person, Bed Mobility = extensive one person ROM (range of motion) =no issues Record review of Resident #1's Care Plan, dated [DATE], revealed: (R#1) wishes to be: FULL CODE - YES Cardiopulmonary Resuscitation (dated [DATE]). (R#1) has Potential for alteration in Cardiopulmonary, cerebral and renal tissue perfusion related to Chronic [CONDITION(S)] (hypertension). Interventions: ( R#1) will maintain optimal cardiac output as evidenced by blood pressure remaining with in own normal range, regular respiratory rate, no SOB, clear lung sounds and absence of [CONDITION(S)] over the Assess vital signs as ordered .Medication as per MD orders (initiated [DATE]) .Monitor and document any signs of altered level of consciousness, change in alertness, agitation and impaired thought process Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was full code status, ordered on [DATE]. Record review of RN A's nurse notes read as follows: Effective Date: [DATE] 04:15 Type: Health Status Note Text: 4:15 CNA alerted this nurse that the patient was unresponsive, and blood was on the floor. This nurse immediately ran in the room and found the patient unresponsive with a large amount of blood on the bed sheets and the floor. Assessed patient: no pulse, no respirations noted. This nurse sent for help, AED and initiated CPR. 911 was called at this time. Author: (RN A) - Registered Nurse [e-SIGNED]. Effective Date: [DATE] 04:35 Type: Health Status EMT arrived, 2 EMT's on site and took over compressions. This nurse assisted EMT's with CPR. AED never initiated a shock throughout CPR. Author: (RN A) - Registered Nurse [e-SIGNED]. Effective Date: [DATE] 04:53cType: Health Status Note Text: EMT's stopped CPR at 4:53am. A police officer was present in the patients room the entire time. Resident Name: R #1 .(family member) arrived at this time and was very upset. Emotional support was given, explanation of situation was given. (family member) was crying and in shock. Police case # 432 , ME case#,d+[DATE], time given to family for viewing and visiting in private before funeral home was notified. Author: (RN A) - Registered Nurse [e-SIGNED]. Effective Date: [DATE] 06:40 Type: No Type Specified . funeral home notified at this time. Author: (RN A) - Registered Nurse [e-SIGNED]. Effective Date: [DATE] 06:45 (6:45 AM) .Type: No Type Specified .Note Text: Post mortem care given at this time, body was washed and repositioned, linen was changed. During care blood was noted under patients right hand, fingernails and an abrasion to her left inguinal area (defined as the groin), (family member) was made aware and acknowledged findings No other abnormal findings noted. Body was prepared for funeral home . Author: (RN A) - Registered Nurse [e-SIGNED]. Record review of RN A's written statement, dated [DATE], read, At 4:15 AM CNA (B) notified me that she found (R#1) unresponsive in her bed .I ran in the room and found the patient unresponsive with a large amount of blood in the bed and on the floor. No active bleeding was found, no pulse and no breathing. I sent the CNA to get help from the other units and initiated CPR. The AED was fetched and attached. At this time 911 was called. CPR was performed and when the EMT's came they took over .timeline: 3:50 checked pt. (patient).4:15 found PT (patient) .4:18 called 911 .4:20 CPR and AED start . Record review of RN A's nurse discharge note (late entry [DATE] at 7:49 PM) read: .4:15am patient found unresponsive, no pulse, no respirations. The bed and the floor were covered in a large amount of blood. At this time there was no active bleeding present. CPR was initiated, 911 was called. AED was attached, CPR was given until EMT's arrived and took over, this nurse assisted. CPR was given until at 4:53 EMT's said to stop. Patient passed away at 4:53. (family member) arrived at this time and was very upset, emotional support was given. ME (Medical Examiner) released body, case #,d+[DATE] . Time was given to family for viewing. Post mortem care was provided. Body was picked up .funeral home at 10:11am per families choice . Record review of law enforcement case card revealed, case # assigned 432. Record review of facility in-service training was sheet, dated [DATE], revealed 8 out of 23 nurses (LVN/RN) received training. Topics addressed included, reviewed expectations for rounding, review emergency response procedures . Record review of Daily Nurse Staffing Form, dated [DATE] (7 PM to 7 AM) revealed, LVN=2; CNA=4; RN=1 (night shift). Record review of Progress Notes dated [DATE]-[DATE] revealed no notes from LVN C or LVN D about their assessment or role surrounding the events of R #1 requiring CPR on [DATE]. Record review of RN A's employee file revealed, RN A had training on BLS (basic life support) on [DATE]. Record review of RN A's facility training transcript (RELIAS) revealed, completion of the following training: o Accident Prevention Management completed [DATE]. o BLS in-person completed [DATE]. o CPR Certification completed [DATE]. o Abuse/Neglect completed [DATE]. During telephone interview on [DATE] at 2 PM, family member stated, .the resident should have not died this way (bleeding to death) .the nursing staff should have checked on her there was blood on her shirt and bedspread and floor .no one told me the cause of death .except that she might have pulled the [CONDITION(S)] port .I am the RP (responsible party) .I will send you pictures . [Family member did not identify the staff member who told him about the cause of death.] Observation (Surveyor and Administrator) and interview on [DATE] at 3:53 PM of recording of camera 18 Unit 6, room [ROOM NUMBER], revealed, CNA B entered R#1's room (room [ROOM NUMBER]) on [DATE] at 11:58 PM and exited at 11:59 PM with rolling vital machine. On [DATE] at 3:50 AM, no entry was made by RN A into Resident#1's room (room [ROOM NUMBER]). CNA B re-entered R#1's room on [DATE] at 4:21 AM and exited at 4:21 AM. From 4:21AM to 4:23 AM, RN A is seen on the telephone, which was not at or near room [ROOM NUMBER] . At 4:25 AM, LVN C and LVN D entered room [ROOM NUMBER]. At 4:27 AM, RN A entered the room (327). At 4:35 AM, LVN D brought AED crash into the room [ROOM NUMBER]. At 4:42 AM, EMS and law enforcement arrived. During an interview after the recording ended, the Administrator confirmed the timeline viewed on camera 18, Unit 6, room [ROOM NUMBER]. During an interview on [DATE] at 9:39 AM, LVN I stated, .I saw the resident (R#1) on [DATE] .I came in on [DATE] and saw the resident deceased .I saw the blood on the bed, floor, and on the patient's hand and left finger, on her face .the (family member) was present .the family member might have taken pictures .I saw the resident around 8:00 AM deceased .no idea what time the incident occurred .the police was called by the night shift and EMS was called .the (family member) was the RP .CPR was done at night before EMS arrived . During an interview on [DATE] at 12:14 PM, CNA B, stated, .Resident (#1) wanted her door closed at night and the lights turned off .my schedule on [DATE] was to check on the resident at midnight and 4 AM .I was supposed to check temperature and 02 (saturation) through the finger measuring device .the Nurse is supposed to check on the resident about every 2 hours .at midnight the resident was asleep .no distress and no blood .I took her temperature .and 02 .I wrote the results on a sheet of paper and gave it to (RN A) .I do not remember whether (RN A) went to check on the resident between the hours of midnight and 4:15 AM .I entered (R#1's) room at 4:15 AM [time of camera recording was 4:21 AM] and I saw massive blood stains on the sheet, on the floor, and on the resident .I called (RN A)[time of camera recording was 4:21 AM] and she told me to get help from the other nurses I don't know if (RNA) was in the room with (R#1) [time of camera recording was 4: 21; RN A was at the Nurse Station on the telephone and not in R#1's room] .a Full Code was called (I do not know who called the code) .I went downstairs to get the other nurses [time of camera recording 4:21 AM] .then I left to do rounds with other residents .I was off the next 2 days and returned to work on Friday .I was in-serviced on doing rounds and how to proceed when we have an incident like the one on [DATE] .I leaned about emergency procedures and to check on residents, at a minimum, every two hours . During an interview on [DATE] at 12:42 PM, the DON stated, the resident was full code requiring CPR and AED (automatic electronic defibrillator) .I received a call from (RN A) on [DATE] at 4:28 AM .RN A stated, resident (R#1) found unresponsive and resident (R#1) bled from the [CONDITION(S)] site .Full Code called .the time line given by (RN A) was: (RN A) checked on the resident at 3:50 AM .at 4:15 AM the CNA (B) found resident unresponsive with blood .CPR started at 4:20 AM .CPR stopped at 4:53 AM .(RN A) was terminated for documentation issues .there were chart errors on the incident on [DATE] .time line seemed off .there are no witnesses that verify RN A saw the patient after the shift started at 7 PM .I investigated the incident .I was not sure what happened .she (R#1) had blood underneath her nails .I turned my evidence to the Administrator .it was not an injury of unknown origin .I found no neglect on the nursing part .I did an internal investigation .not a formal incident report . During an interview on [DATE] at 3:40 PM, RN A stated, At first I did the compression .for about 15 minutes .another nurse was doing breathing (LVN C) no active bleeding .checked her pulse .no pulse .no breathing no active bleeding .(R#1) unresponsive .spoke to the resident .no response to questions .checked breathing and pulse .my assessment was that resident had no vital signs .I called 911 the light switch was on .the Aide (CNA B) turned it on .Resident (#1) was a full code .the other nurse (LVN D) got the AED and put it on .the AED did not prompt to shock her the bed board was put on her back for firm surface .CPR done on the bed board .I do not remember whether I entered the room between midnight and 4:15 AM. [Surveyor did not contradict RN A on the inconsistencies concerning her timeline] During a telephone interview on [DATE] at 3:45 PM LVN D stated .I followed (LVN C) into the room .and assessed (R#1) and I was the nurse that did the AED .I checked for pulse, breathing, and skin temperature .no active bleeding . I left to get the crash cart with the AED; and returned . (RN A) got the crash cart .I grabbed the AED .bed board placed by LVN C .I was monitoring the AED .it never triggered to shock .resident never responded .EMT and law enforcement arrived . During a telephone interview on [DATE] at 4:33 PM, LVN C stated, .I came into the room and the resident had blood all over .not breathing .lips purple .I started CPR .crash cart arrived .in the beginning , I did the compression .(RN A) arrived and started the compression .then I did the breathing .she had no pulse .EMT and police arrived .I do not know how the bleeding started . During a telephone interview on [DATE] at 5:38 PM, facility MD stated, .the facility has been trained on basic CPR with 911 being the backup .I do not know how long it would take a resident to bleed from a punctured fistula .a forensic physician would know the answer .I was informed about the incident the day after ([DATE]), in the morning ([DATE]) .the resident was on three blood thinners .anemic and elderly .there was order for the close monitoring of the resident . During an interview on [DATE] at 6:08 PM, RN A stated, I immediately entered the room .I did not stop to call 911 .or to call anyone .I immediately followed the CNA B into the room. During a telephone interview on [DATE] at 6:21 PM, LVN C stated, .there was no other nurse in the room when I arrived . [camera time of arrival was 4:25 AM]. Attempted telephone interview on [DATE] at 6:24 PM, message left for EMS Division to call surveyor. Message was not returned by the end of the survey on [DATE]. During an interview on [DATE] at 9:15 AM, the Administrator re-confirmed the timeline observed on [DATE] at 3:53 PM of recording of camera 18 Unit 6, room [ROOM NUMBER]. The Administrator stated, .that was the timeline I saw . During an interview on [DATE] at 3:00 PM, DON stated, the facility used the American Heart Association Guidelines on CPR as the facility's CPR policy [2010 American Heart Association Guidelines includes to assess and begin CPR immediately if cardiac arrest is likely.]. During an interview on [DATE] at 7:15 PM, DON stated, (RN A) was officially terminated on [DATE]. She returned to the facility on [DATE] to complete her documentation (of the incident on [DATE]) but did not work the floors . Record review of facility's policy titled Automated External Defibrillators (AEDs), dated [DATE], page 4 read, .Guidelines 1. Licensed nursing staff, in addition to maintain current cardiopulmonary/resuscitation (CPR) certification, will maintain current training/certification in the use of the AED . 5. The facility, in conjunction with the Medical Director (as needed), conducts quarterly mock drills in AED device use and presents findings to the Quality Assurance and Performance Improvement (QAPI) Committee as appropriate for further evaluation. Documentation 1. In the event that the AED is used, document use in the medical record. Record review of facility's policy titled, Advance Directives, dated [DATE], read, .Social Work Services or designee will inquire of the resident .about the existence of any written advance directives .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . Record review Facility Emergency Management Code Sheet, undated, revealed, Code Blue was listed as a medical emergency. Record review of facility Abuse policy, dated [DATE], read, .Neglect is defined as 'the failure of the facility, its employees or service providers to provide goods and services to resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress' .Reporting .The Administrator or designee will notify the appropriate agencies immediately; as soon as possible, but no later than 24 hours after the discovery of the incident. In the case of serious bodily injury, no later than 2 hours after the discovery .When an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury is reported .The Administrator or Director of Nursing will conduct the investigation . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on [DATE] at 11:30 AM; and a plan of removal was requested. On [DATE] at 5:45 PM, the facility provided a plan of removal and it was accepted on [DATE] at 10:33 AM. It was documented as follows: [Name of Facility] . Plan of Removal Regarding IJ #2 Issued on [DATE]- @ 1545 Hours Quality of Life: Actions: Immediate . DON / ADON's will continue to Provide Inservice to all nursing staff, licensed and unlicensed regarding the following topics: o Initiation Date: Staff in services began on [DATE]. o Mock Codes Mock Codes will be conducted quarterly, beginning Q4 2021, beginning [DATE], rotating on 8-hour time blocks (,d+[DATE], ,d+[DATE], ,d+[DATE]). I.e., Q1 Mock code will occur on ,d+[DATE]-time block, Q2 Mock code will occur on ,d+[DATE]-time block, Q3 Mock code will occur on ,d+[DATE] time block etc. DON / ADON or licensed nurse designee will implement and supervise performance of staff during mock code. Areas of concern identified by Mock Code Assessor, will be shared one on one with identified individual. Identified Individual will receive one on one remedial training on code process. Individual will be re-assessed for competency. o Audit CPR Records of Licensed Staff CPR Audit on licensed nursing staff has been completed, facility has copy of all licensed Full Time Nurses CPR card. Licensed nurses will not be permitted to provide patient care until CPR card is verified on file, with facility. Newly hired staff will be required to provide proof of BLS documentation prior to training or providing direct patient care. o Licensed Staff to initiate CPR if indicated o Staff will be in serviced on the above listed topics prior to start of each shift or sooner before being allowed to assume patient care/ return to work o Anticipated date of completion for in-services is [DATE] @ 23:59 hours. Long Term QA Committee will continue to monitor systems developed at Monthly QA Meeting Persons Responsible: Administrator Director of Nursing Assistant Directors of Nursing Anticipated date of completion: [DATE] @ 2359 Hours LNFA Administrator Verification of the Plan of Removal: Record review of 23 of 23 LVN's/RN's CPR cards were reviewed and all were current. Observation on [DATE] of a Mock Code at 1:16 pm. 911 was not activated until 1:19 pm. LVN did not delegate anyone to record events. At 1:17 PM of paging system revealed, the overhead system functioned appropriately as a Code Blue was initiated by the DON. Further observation of the Mock Exercise revealed, Medication Aide V was directed by LVN X to call 911. Medication Aide V simulated a call to 911. [Mock exercise (day shift) ran from 1:17 PM to 1:22 PM]. Observation of Mock Code on [DATE] at 7:23 PM revealed LVN S took the lead, assessed and no response or respirations, initiated chest compressions, delegated LVN T to call 911 and announce the Code Blue, delegated a member of the nursing department to retrieve the crash cart and AED machine, and delegated a nursing staff member to take note of the events. AED leads placed on Mannequin, Ambu bag placed, nursing staff rotated compressions and ambu bag respirations. Much more effective management of the code blue during the second observation. During an interview on [DATE] at 1:22 PM, Medication Aide V stated, .I called 911 as instructed by the nurse .at hearing the Code Blue and the location of the resident, I got the crash cart and brought it to room [ROOM NUMBER] (Unit 3) .when calling the police, I would mention the nature of the emergency, provide any information needed, and request assistance .per the in-service I received, I will not leave the resident alone .and the nurse will remain with the resident providing emergency treatment .also, I checked the Full Code list to ensure the resident was a full code .after the emergency is over .I will provide the nurse a sheet of paper with the time I checked the Full Code list, the time I got the crash cart, and the time I called the Police . During an interview on [DATE] at 3:51 PM, LVN N confirmed received an in-service regarding codes and CPR. LVN N revealed the ADON was the CPR instructor who would recertify BLS certification. LVN N stated you would never leave a patient alone and code status would be verified prior to conducting CPR. During an interview on [DATE] at 4:38 PM, CNA Y confirmed receiving an in-service yesterday ([DATE]) about CPR, codes and what to do. During an interview on [DATE] at 4:46 PM, LVN X confirmed receipt of an in-service to include: Codes, AED, crash cart. During an interview on [DATE] at 4:55 PM, CNA R confirmed an in-service was that included: Emergencies, Codes, how to announce a code blue, and further confirmed the in-service included if you find a resident unresponsive you call for the nurse, do not leave the resident. Call 911 once the nurse is there. CNA R further revealed the nurse would provide CPR or anyone certified in CPR. During an interview on [DATE] at 7:32 PM, employees confirmed they had received training regarding: code status, initiation of CPR, announcing the code, use of the AED, documentation, what to do if you find a resident unresponsive, and to not the a resident unattended if unresponsive. The following employees confirmed receipt of training: LVN N, CNA R, CNA Z, Medication Aide V, LVN/ADON L, LVN B, Medication Aide Q, RN H, LVN P, LVN S, LVN G, LVN F, ADON K, LVN E, and LVN D. 9 nursing staff employees have not received training due to leave or as needed status. Those individuals will not be allowed to work until they have had the above training. Total nursing staff employees who have received training for change in condition and LVN/RN documenting assessment in the electronic medical record, overhead paging to announce, Code Blue, and actual Mock Code training: 48 out of 54 (CNA's, Restorative Aides, Medication Aides, LVN's, and RN's).

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 Residents (R #1) whose records were reviewed for quality of care, in that: -RN A did not immediately assess R#1 after notification from CNA B that R #1 was unresponsive, which resulted in a delay of providing life saving measures. These deficient practices could affect residents and could result in a deterioration of their physical condition, including death. These failures resulted in an IJ on [DATE] at 3:45 PM. While the IJ was removed on [DATE] at 11:30 AM, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope of isolated due to facility's need to evaluate the effectiveness of their plan of removal and complete training. The findings were: Record review of R#1's face sheet, dated [DATE], and EMR (electronic medical record) revealed, R #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#1 age 68. Advanced Directive indicated R #1 was a Full Code. RP (responsible party) was listed as: a family member. Record review of R #1's 5-day assessment of the MDS (minimum data set), dated [DATE], revealed, a BIMS (brief interview of mental status) score of 13, which indicated R #1 was cognitively intact). ADLs (activities of daily living) revealed R #1 was continent of bowel and bladder and required supervision one person. R #1 required extensive assistance of 2 persons for transfers. R #1 required extensive assistance of 1 person for bed mobility. Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS confirmed in section O Special Treatments, that R #1 received [CONDITION(S)] while being in the facility. Record review of R#1's Care Plan, dated [DATE], revealed R #1 wishes to be: FULL CODE - YES Cardiopulmonary Resuscitation. (R#1) has Potential for alteration in Cardiopulmonary, cerebral and renal tissue perfusion related to Chronic [CONDITION(S)] (hypertension). Interventions: ( R#1) will maintain optimal cardiac output as evidenced by blood pressure remaining within own normal range, regular respiratory rate, no SOB, clear lung sounds and absence of [CONDITION(S)] over the Assess vital signs as ordered .Medication as per MD orders (initiated [DATE]) .Monitor and document any signs of altered level of consciousness, change in alertness, agitation and impaired thought process Record review R #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was a Full Code Status ordered on [DATE]. Record review of RN A's progress notes read as follows: Effective Date: [DATE] 04:15 Type: Health Status Note Text: 4:15 CNA alerted this nurse that the patient was unresponsive, and blood was on the floor. This nurse immediately ran in the room and found the patient unresponsive with a large amount of blood on the bed sheets and the floor. Assessed patient: no pulse, no respirations noted. This nurse sent for help, AED and initiated CPR. 911 was called at this time. Author: (RN A) - Registered Nurse [e-SIGNED]. Effective Date: [DATE] 04:35 Type: Health Status: EMT arrived, 2 EMT's on site and took over compressions. This nurse assisted EMT's with CPR. AED never initiated a shock throughout CPR. Author: (RN A) - Registered Nurse [e-SIGNED]. Effective Date: [DATE] 04:53 Type: Health Status Note Text: EMT's stopped CPR at 4:53am. A police officer was present in the patients room the entire time. R#1 . (family member) arrived at this time and was very upset. Emotional support was given, explanation of situation was given. (family member) was crying and in shock.Police case # 432, ME case#,d+[DATE], time given to family for viewing and visiting in private before funeral home was notified. Author: (RN A) - Registered Nurse [e-SIGNED]. Effective Date: [DATE] 06:40 Type: No Type Specified . funeral home notified at this time. Author: (RN A) - Registered Nurse [e-SIGNED]. Effective Date: [DATE] 06:45 (6:45 AM) .Type: No Type Specified .Note Text: Post mortem care given at this time, body was washed and repositioned, linen was changed. During care blood was noted under patients' right-hand fingernails and an abrasion to her left inguinal area, (defined as groin) (family member) was made aware and acknowledged findings No other abnormal findings noted. Body was prepared for funeral home . Author: (RN A) - Registered Nurse [e-SIGNED]. Record review of RN A's written statement, dated [DATE], read, At 4:15 am CNA (B) notified me that she found (R#1) unresponsive in her bed .I ran in the room and found the patient unresponsive with a large amount of blood in the bed and on the floor. No active bleeding was found, no pulse and no breathing. I sent the CNA to get help from the other units and initiated CPR. The AED was fetched and attached. At this time 911 was called. CPR was performed and when the EMT's came they took over .timeline: 3:50 checked pt. (patient).4:15 found PT (patient) .4:18 called 911 .4:20 CPR and AED start . Record review of RN A's nurse discharge note (late entry [DATE] at 7:49 PM) read: .4:15am patient found unresponsive, no pulse, no respirations. The bed and the floor were covered in a large amount of blood. At this time there was no active bleeding present. CPR was initiated, 911 was called. AED was attached, CPR was given until EMT's arrived and took over, this nurse assisted. CPR was given until at 4:53 EMT's said to stop. Patient passed away at 4:53. (family member) arrived at this time and was very upset, emotional support was given. ME (Medical Examiner) released body, case #,d+[DATE] . Time was given to family for viewing. Post mortem care was provided. Body was picked up .funeral home at 10:11am per families choice . Record review of law enforcement case card revealed, case # assigned was 432. Record review of facility in-service training sheet, dated [DATE], revealed, 8 out of 23 nurses (LVN/RN) received training. Topics addressed included, .reviewed expectations for rounding, review emergency response procedures . Record review of Daily Nurse Staffing Form dated [DATE] (7 PM to 7 AM) revealed, LVN=2; CNA=4; RN=1 (night shift). Record review of progress notes dated [DATE]-[DATE] revealed no notes from LVN C or LVN D surrounding the events of R #1's assessment and events of Code Blue/CPR administration on [DATE]. Record review of RN A's employee filed revealed, she had training on BLS (basic life support) on [DATE]. Record review of RN A's facility training transcript (RELIAS) revealed, completion of the following training: o Accident Prevention Management completed [DATE]. o BLS in-person completed [DATE]. o CPR Certification completed [DATE]. o Abuse/Neglect completed [DATE]. Observation (Surveyor and Administrator) and interview on [DATE] at 3:53 PM of recording of camera 18, Unit 6, room [ROOM NUMBER], revealed, CNA B entered R #1's room (room [ROOM NUMBER]) on [DATE] at 11:58 PM and exited at 11:59 PM with the rolling vital machine. On [DATE] at 3:50 AM, no entry was made by RN A into Resident#1's room (room [ROOM NUMBER]). CNA B re-entered R #1's room on [DATE] at 4:21 AM and exited at 4:21 AM. From 4:21AM to 4:23 AM, RN A is seen on the telephone at the nurses' station, which was not at or near room [ROOM NUMBER]. At 4:25 AM, LVN C and LVN D entered the room. At 4:27 AM, RN A entered the room. At 4:35 AM, LVN D brought the AED (automatic external defibrillator) and the crash into the room. At 4:42 AM, EMS and law enforcement arrived. During an interview after the recording ended, the Administrator confirmed the timeline viewed on camera 18, Unit 6, room [ROOM NUMBER]. During a telephone interview on [DATE] at 10:09 AM, RN A stated, .Resident (#1) bled to death .my Nurse Aide (CNA B) came to me around 4:15 AM [time of camera recording was 4:21 AM] to tell me the Resident (#1) was bleeding .I went into the room [time of camera recording RN # 1 entered R#1's room at 4:27 AM] .there was a lot of blood on the linen and the floor .I got help .and told the Nurse Aide (CNA B) to get other nurses .I called 911 .I started CPR .and administered 02 (oxygen) to the resident .I did the compressions and another nurse (LVN C) did the breathing .the resident did not respond .EMS arrived in 15 minutes [time of camera recording was 4:42 AM] .I was released from the compressions .more EMT arrived .police arrived also with EMT .the family and physician were called by the EMT .we stopped CPR at 4:53 AM .the EMT called their doctor .the EMT per the MD gave order to stop .the body remained .we make rounds at night .I do not remember when I actually saw before 4:15 AM .do not know about in-service training given after the incident .I have not received in-service training .I have been terminated .because of the timeframe was not right .I should have been checking on the Resident (R #1) within the time frame, every two hours .I worked 7 PM to 7AM .I saw the Resident (#1) when I started the shift .no bleeding and everything was fine with the fistula . During an interview on [DATE] at 12:14 PM, CNA B, stated, .Resident (#1) wanted her door closed at night and the lights turned off .my schedule on [DATE] was to check on the resident at midnight and 4 AM .I was supposed to check temperature and 02 (saturation) through the finger measuring device .the Nurse is supposed to check on the resident about every 2 hours .at midnight the resident was asleep .no distress and no blood .I took her temperature .and oxygen saturation .I wrote the results on a sheet of paper and gave it to RN A .I do not remember whether (RN A) went to check on the resident between the hours of midnight and 4:15 AM .I entered (R#1's) room at 4:15 AM [time of camera recording was 4:21 AM] and I saw massive blood stains on the sheet, on the floor, and on the resident .I called (RN A)[time of camera recording was 4:21 AM] and she told me to get help from the other nurses I don't know if (RN A) was in the room with (R#1) [time of camera recording was 4: 21; RN A was at the Nurse Station on the telephone and not in R#1's room] .a Full Code was called (I do not know who called the code) .I went downstairs to get the other nurses [time of camera recording 4:21 AM] . During an interview on [DATE] at 12:42 PM, the DON stated, .monitoring is done every shift and as needed .the resident was full code requiring CPR and AED (automatic electronic defibrillator) .I received a call from (RN A) on [DATE] at 4:28 AM .RN A stated, R #1 found unresponsive and resident bled from the [CONDITION(S)] site .Full Code called .the time line given by (RN A) was: (RN A) checked on the R #1 at 3:50 AM .at 4:15 AM the CNA (B) found resident unresponsive with blood .CPR started at 4:20 AM .CPR stopped at 4:53 AM .(RN A) was terminated for documentation issues .there chart errors on the incident on [DATE] .time line seemed off .there are no witnesses that verify she saw the patient after the shift started at 7 PM .I investigated the incident .I was not sure what happened .she (R#1) had blood underneath her nails .I turned my evidence into the Administrator .it was not an injury of unknown origin .I found no neglect on the nursing part .I did an internal investigation .not a formal incident report . During an interview on [DATE] at 3:40 PM, RN A stated, At first I did the compression .for about 15 minutes .another nurse was doing breathing (LVN C) no active bleeding .checked her pulse .no pulse .no breathing no active bleeding .(R#1) unresponsive .spoke to the resident .no response to questions .checked breathing and pulse .my assessment was that resident had no vital signs .I called 911 the light switch was on .the Aide (CNA B) turned it on .Resident (#1) was a full code .the other nurse (LVN D) got the AED and put it on .the AED did not prompt to shock her the bed board was put on her back for firm surface .CPR done on the bed board .I do not remember whether I entered the room between midnight and 4:15 AM. During a telephone interview on [DATE] at 3:45 PM LVN D stated, .I followed (LVN C) into the room [time of camera recording was 4:25 AM] .and assessed (R#1) and I was the nurse that did the AED .I checked for pulse, breathing, and skin temperature .no active bleeding . I left to get the crash cart [time of camera recording 4:25 AM] with the AED; and returned [time of camera recording 4:35 AM] . (RN A) got the crash cart .I grabbed the AED .bed board placed by LVN C .I was monitoring the AED .it never triggered to shock .resident never responded .EMT and law enforcement arrived [time of camera recording was 4:42 AM] . During a telephone interview on [DATE] at 4:33 PM, LVN C stated, .I came into the room [time of camera recording was 4:25 AM] and the resident had blood all over .not breathing .lips purple .I started CPR .crash cart arrived .in the beginning , I did the compression .(RN A) arrived and started the compression .then I did the breathing .she had no pulse .EMT and police arrived .I do not know how the bleeding started . During a telephone interview on [DATE] at 5:38 PM, facility MD stated, .the facility has been trained on basic CPR with 911 being the backup .I do not know how long it would take a resident to bleed from a punctured fistula .a forensic physician would know the answer .I was informed about the incident the day after ([DATE]), in the morning ([DATE]) .the resident was on three blood thinners .anemic and elderly .there was order for the close monitoring of the resident . During a joint interview with the Administrator and DON on [DATE] at 5:47 PM, the Administrator stated, .my expectation is that the staff respond by the American Association Guideline I would need to check the time line for response .we are training 100% of the staff .respond quickly, assess the situation, take vitals, and then begin compressions and breathing . The Administrator stated that the staff followed the American Heart Association for CPR and BLS (basic life support). During an interview on [DATE] at 6:08 PM, RN A stated, I immediately entered the room .I did not stop to call 911 .or to call anyone .I immediately followed the CNA B into the room [camera video evidence of timeline did not support the latter statement]. During a telephone interview on [DATE] at 6:21 PM, LVN C stated, .there was no other nurse in the room when I arrived . [camera time of arrival was 4:25 AM]. During an interview on [DATE] at 9:15 AM, the Administrator re-confirmed the timeline observed on [DATE] at 3:53 PM of the recording of camera 18, Unit 6, room [ROOM NUMBER]. The Administrator stated, .that was the timeline I saw . During an interview on [DATE] at 11:30 AM, Administrator revealed there is not specific policy for conducting nursing assessments. During an interview on [DATE] at 3:00 PM, DON stated, the facility used the American Heart Association Guidelines on CPR as the facility's CPR policy [2010 American Heart Association Guidelines includes to assess and begin CPR immediately if cardiac arrest is likely.]. During an interview on [DATE] at 4:05 PM, CNA O stated, if a resident was observed unresponsive, I would turn on the call light and yell from the door for help, and I would not leave the resident alone. CNA O confirmed the nurse would start CPR (cardiopulmonary resuscitation) because the CNA's were not certified to provide CPR. CNA O revealed any staff can call the code or 911. CNA O revealed to call a CODE BLUE, in the past staff would call the operator and the operator would announce the CODE BLUE. CNA O further revealed if the receptionist/operator was not available, then staff would have to go to the receptionist desk and call overhead to announce the code. During an interview on [DATE] at 4:11 PM, LVN P confirmed a runner (person who would go to another location to complete the assignment) would have to go up the stairs to the main desk to use the microphone to make an announcement. LVN P further revealed in the morning shift, if a resident code took place, staff could dial 0 for the receptionist and have the receptionist announce the code blue. During an interview on [DATE] at 4:17 PM, Medication Aide Q revealed if a resident was found unresponsive, staff would use the intercom to announce a code. Medication Q further revealed staff can run to the main receptionist desk to announce overhead or call from the nurses' station telephone to the receptionist and ask the receptionist to announce. Medication Aide Q confirmed the phone intercom is disabled. During an interview with on [DATE] at 4:55 PM, CNA R revealed staff would have to go upstairs to announce a code blue. CNA R further revealed the nurse would provide CPR or anyone certified in CPR if needed. The Administrator was notified of the Immediate Jeopardy {IJ} on [DATE] at 11:30 AM. Record review of facility Emergency Procedure-Cardio-pulmonary Resuscitation policy, dated revised 2018, read, .1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events .3. Chest Compressions: a. Following initial assessment, begin CPR with chest compressions . On [DATE] at 5:45 PM, the facility provided a plan of removal and it was accepted on [DATE] at 10:33 AM. It was documented as follows: .(Facility Name) Plan of Removal Regarding IJ #1 Issued on [DATE]- @ 1545 Hours Quality of Care: Actions: Immediate DON / ADON's will continue to Provide Inservice to all nursing staff, licensed and unlicensed regarding the following topics: o Initiation Date: Staff in services began on [DATE]. o Mock Codes Mock Codes will be conducted quarterly, beginning Q4 2021, beginning [DATE], rotating on 8-hour time blocks (,d+[DATE], ,d+[DATE], ,d+[DATE]). I.e., Q1 Mock code will occur on ,d+[DATE]-time block, Q2 Mock code will occur on ,d+[DATE]-time block, Q3 Mock code will occur on ,d+[DATE] time block etc. Mock Code education and return demonstration initiated on [DATE]. Observation on [DATE] of a Mock Code at 1:16 pm. 911 was not activated until 1:19 pm. LVN did not delegate anyone to record events. Mock Code observed on [DATE] at 7:23 PM. LVN took the lead, assessed and no response or respirations, initiated chest compressions, delegated an LVN to call 911 and announce the Code Blue, delegated a member of the nursing department to retrieve the crash cart and AED machine, and delegated a nursing staff member to take note of the events. AED leads placed on Mannequin, Ambu bag placed, nursing staff rotated compressions and ambu bag respirations. Much more effective management of the code blue during the second observation. DON / ADON or licensed nurse designee will implement and supervise performance of staff during mock code. DON and both ADON's were involved in implementing and supervising the Mock Code performance. Areas of concern identified by Mock Code Assessor, will be shared one on one with identified individual. Identified Individual will receive one on one remedial training on code process. Individual will be re-assessed for competency. o Audit CPR Records of Licensed Staff CPR Audit on licensed nursing staff has been completed, facility has copy of all licensed Full Time Nurses CPR card. Licensed nurses will not be permitted to provide patient care until CPR card is verified on file, with facility. Newly hired staff will be required to provide proof of BLS documentation prior to training or providing direct patient care. Record review of facility BLS binder, undated, revealed that 23 licensed nursing staff (LVN/RN) had documentation of current BLS training (CPR)-see attached spreadsheet. 23 of 23 LVN's/RN's CPR cards were reviewed and all were current. Licensed Staff to initiate CPR if indicated. Anticipated date of completion for in-services is [DATE] @ 23:59 hours. Long Term QA Committee will continue to monitor systems developed at Monthly QA Meeting Persons Responsible: Administrator Director of Nursing Assistant Directors of Nursing Anticipated date of completion: [DATE] @ 2359 Hours LNFA Administrator . Verification of the Plan of Removal: Record review of 23 of 23 LVN's/RN's CPR cards were reviewed and all were current. Observation on [DATE] of a Mock Code at 1:16 pm. 911 was not activated until 1:19 pm. LVN did not delegate anyone to record events. Observation on [DATE] at 1:17 PM of paging system revealed, the overhead system functioned appropriately as a Code Blue was initiated by the DON. Further observation of the Mock Exercise revealed, Medication Aide V was directed by LVN X to call 911. Medication Aide V simulated a call to 911. [Mock exercise (day shift) ran from 1:17 PM to 1:22 PM]. Observation of Mock Code on [DATE] at 7:23 PM revealed LVN S took the lead, assessed and no response or respirations, initiated chest compressions, delegated LVN T to call 911 and announce the Code Blue, delegated a member of the nursing department to retrieve the crash cart and AED machine, and delegated a nursing staff member to take note of the events. AED leads placed on Mannequin, Ambu bag placed, nursing staff rotated compressions and ambu bag respirations. Much more effective management of the code blue during the second observation. During an interview on [DATE] at 1:22 PM, Medication Aide V stated, .I called 911 as instructed by the nurse .at hearing the Code Blue and the location of the resident, I got the crash cart and brought it to room [ROOM NUMBER] (Unit 3) .when calling the police, I would mention the nature of the emergency, provide any information needed, and request assistance .per the in-service I received, I will not leave the resident alone .and the nurse will remain with the resident providing emergency treatment .also, I checked the Full Code list to ensure the resident was a full code .after the emergency is over .I will provide the nurse a sheet of paper with the time I checked the Full Code list, the time I got the crash cart, and the time I called the Police . During an interview on [DATE] at 3:51 PM, LVN N confirmed received an in-service regarding codes and CPR. LVN N revealed the ADON was the CPR instructor who would recertify BLS certification. LVN N stated you would never leave a patient alone and code status would be verified prior to conducting CPR. During an interview on [DATE] at 4:38 PM, CNA Y confirmed receiving an in-service yesterday ([DATE]) about CPR, codes and what to do. During an interview on [DATE] at 4:46 PM, LVN X confirmed receipt of an in-service to include: Codes, AED, crash cart. During an interview on [DATE] at 4:55 PM, CNA R confirmed an in-service was that included: Emergencies, Codes, how to announce a code blue, and further confirmed the in-service included if you find a resident unresponsive you call for the nurse, do not leave the resident. Call 911 once the nurse is there. CNA R further revealed the nurse would provide CPR or anyone certified in CPR. During an interview on [DATE] at 7:32 PM, employees confirmed they had received training regarding: code status, initiation of CPR, announcing the code, use of the AED, documentation, what to do if you find a resident unresponsive, and to not the a resident unattended if unresponsive. The following employees confirmed receipt of training: LVN N, CNA R, CNA Z, Medication Aide V, LVN/ADON L, LVN B, Medication Aide Q, RN H, LVN P, LVN S, LVN G, LVN F, ADON K, LVN E, and LVN D. 9 nursing staff employees have not received training due to leave or as needed status. Those individuals will not be allowed to work until they have had the above training. Total nursing staff employees who have received training for change in condition and LVN/RN documenting assessment in the electronic medical record, overhead paging to announce, Code Blue, and actual Mock Code training: 48 out of 54 (CNA's, Restorative Aides, Medication Aides, LVN's, and RN's).

Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a sanitary environment to help prevent the development and transmission of infections for 1 of 17 Residents (Resident #409) and in 1 of 1 laundry room reviewed for infection control. 1. Resident #409 did not have physician orders for droplet precautions for 8 days after being admitted to facility from the hospital with droplet isolation precautions [MEDICAL CONDITION] in the sputum. 2. Staff did not follow isolation precautions and wear proper PPE to include a face mask, protective gown, and gloves to cover their hands when they entered and provided care to Resident #409. 3. Resident #409 had orders for Droplet Precautions/Isolation [MEDICAL CONDITION] of sputum and did not wear a facial mask each time he left his room and was observed coughing while outside of his room. 4. Facility Housekeeping Staff were not informed of Resident #409's contact isolation precaution [MEDICAL CONDITION] in the sputum. 5. Resident #409 was using the community shower and no droplet/standard isolation precautions wear exercised to disinfect the shower after each use by Resident #409 . These deficient practices resulted in the identification of an Immediate Jeopardy (IJ) on 5/16/19. While the IJ was removed on 5/17/19, the facility remained out of compliance at a level of potential harm with a scope identified as widespread. The findings were: 1. Review of the face sheet for Resident #409 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Center for Disease Control and Prevention (CDC) revealed [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA) is a cause of staph infection that is difficult to treat because of some resistance to antibiotics. Staph infections-including those caused [MEDICAL CONDITION]- can spread in hospitals and other healthcare facilities , retrieved from https://www.cdc.gov/mrsa/index.html on 5/30/19. Review of Resident #409's hospital microbiology sputum culture dated 4/24/19, revealed Resident #409 was Staph [MEDICAL CONDITION] positive refer to MDRO (Multi-Drug Resistant Organism) policy for isolation requirements. Review of Resident #409's Admission Report (written by facility nurse from report received by hospital nurse-no date) revealed resident #409 was on contact isolation [MEDICAL CONDITION] sputum. Review of Resident #409's Admission/Readmission assessment dated [DATE] revealed an admitting [DIAGNOSES REDACTED]. Review of Resident #409's baseline care plan dated 5/6/19 revealed resident was on isolation and had an infection. Review of Resident #409's daily skilled nurses note dated 5/7/19 revealed Resident # 409 continued on isolation [MEDICAL CONDITION] in sputum. Waiting on antibiotics to be delivered from pharmacy. Review of Resident #409's daily skilled nurses note dated 5/8/19 revealed continues on contact isolation [MEDICAL CONDITION] of sputum. Review of Physician's Orders dated 5/16/19 for Resident #409 revealed an order dated 5/14/19 for Droplet Precautions/Isolation [MEDICAL CONDITION] of sputum with no end date. During an interview on 5/16/19 at 5:25 PM with ADON B, revealed Resident #409 should have had an order for [REDACTED]. Review of CDC revealed Droplet transmission is, technically, a form of contact transmission, and some infectious agents transmitted by the droplet route also may be transmitted by the direct and indirect contact routes. However, in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. Using this distance of less than or equal to 3 feet for donning masks has been effective in preventing transmission of infectious agents via the droplet route. Retrieved from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf on 5/30/19. Review of the Medication Administration Record [REDACTED]. Observation on 5/14/19 at 9:49 a.m. revealed Resident #409's door had a sign on it that stated Stop, See the Nurse and a small multi-compartment cabinet with PPE in it placed outside of the room. Observation on 5/14/19 at 10:36 a.m., revealed PTA F provided a pitcher of water to Resident #409 without the use of PPE while in the room. Interview on 5/14/19 at 10:37 a.m. with PTA F revealed that she was aware Resident #409 was on isolation precautions and revealed that she did not follow PPE precautions that included the use of a facial mask, gown, and gloves because it was a quick in and out of the Resident's room. Interview on 5/14/19 at 10:48 a.m., Resident #409 revealed that he believed that he [MEDICAL CONDITION] from unresolved pneumonia in (MONTH) 2019. Observation on 5/16/16 at 10:55 a.m., CNA H was in Resident #409's room cleaning the bedside table and was not wearing PPE that included a facial mask, gown, and gloves. Interview on 5/16/19 at 10:57 a.m.,CNA H revealed that she was aware that Resident #409 was on isolation precautions but revealed that since the resident was not in the room she was not required to wear PPE. CNA H further revealed that she was not aware of the facility policy for the use of PPE. CNA H revealed that Resident #409 was presently in the community shower. During an interview on 5/16/19 at 11:02 a.m., LVN G revealed that Resident #409 was in the community shower room presently and that the Resident could use the community shower room if he was the last resident to use the shower. LVN G further revealed that the CNAs would clean the shower room after each shower. Observation on 5/16/19 at 11:05 a.m., revealed Resident #409 was observed exiting the community shower room in the wheelchair assisted by CNA I. CNA I and Resident #409 were both observed not wearing PPE. Continued observation at this time, revealed Resident #409 actively coughing while exiting the community shower. Resident #409 was assisted down the hallway, passing 4 other resident's rooms with at least 2 residents observed in their rooms and 1 visitor before arriving at his room. Interview on 5/16/19 at 11:07 a.m. with CNA I revealed that she was aware that Resident #409 was on isolation precautions and confirmed that Resident #409 was not wearing PPE as he was assisted out of the community shower. CNA I further revealed that she did not have a mask on when assisting Resident #409 in the shower. CNA I was asked if she knew what type of infection Resident #409 had and she replied, it was in the groin. Interview on 5/16/19 at 11:15 a.m., Housekeeper U revealed that she had cleaned the community shower in the morning and in the afternoon and further revealed that she was not aware of a Resident on isolation precautions using the community shower. Housekeeper U further revealed that she was not informed that a Resident was on isolation precaution by facility staff. Housekeeper U revealed that she was not aware of the facility policy for residents on isolation precautions. Housekeeper U revealed that she did not wear PPE when cleaning the community shower other than gloves. Further interview at this time with Housekeeper U revealed that she worked in different units throughout the facility. Interview on 5/16/19 at 2:53 p.m., the DON revealed that when a Resident was admitted with an infection and required isolation that the staff would be in-serviced by nursing. DON further revealed that a resident on isolation precautions would be required to stay in their room and that PPE would be required by staff who assisted the Resident. The DON confirmed that Resident #409 was on droplet isolation but was not sure whether facility staff had been in-serviced regarding the type of precautions to take. The DON revealed that residents on droplet isolation included wearing PPE that consisted of the use of a mask, gown, gloves, everything. The DON revealed that staff who entered Resident #409's room should be wearing PPE even if the resident was not in the room. The DON stated that Resident #409 should ideally stay in the room but should be wearing a mask when not in the room. Interview on 5/17/19 at 2:31 p.m., RN A, Vice President of Clinical Services, revealed that the issue with non-compliance with isolation precautions was a breakdown in communication from different levels of staff. Review of the facility policy titled Managing Infections, revision date 4/2009, revealed in part .Masks During Droplet Precautions (1) In addition to Standard Precautions, wear a mask when working within 3 feet of the resident .d. Resident Transport (1) Limit movement of resident from the room to essential purposes only. (2) If transport or movement from the room is necessary, place a mask on the infected individual and encourage the resident to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets .The facility is also responsible for notifying transport staff (CNA or Nurse) of residents that require special care due to infectious conditions .e. Resident Care Equipment (2) If use of common items is unavoidable , then adequately clean and disinfect them before use for another resident. The Administrator and the DON were notified on 5/16/19 at 5:23 p.m. that an Immediate Jeopardy (IJ) situation was identified. The facility's Plan of Removal was accepted on 5/17/19 at 1:30 p.m. and included: Residents potentially affected by the findings include 17 residents residing on Unit 3 Immediate actions: 1. CDC PPE training has begun for all staff in housekeeping, nursing, and food service that are currently in the building. This includes nursing night staff that will be working tonight on 5/16/19 at 5:45pm. Sign-in sheets provided. 2. CDC PPE training was resumed at 6 am for all housekeeping staff on 5/17/19. CDC PPE training will begin with all Therapy staff at 7:30 am (5/17/19). 3. CDC PPE training will be done with all nursing staff at shift change at 6 am on 5/17/19. CDC PPE training will also occur tomorrow night (5/17/19) as this will be a new team working. 4. Food service staff was trained on isolation trays immediately. Training will continue before breakfast service tomorrow (5/17/19) for day shift food service staff. Training was done, and sign-in sheets provided. 5. Nursing staff checking for presence of elevated temperatures or infections on Units 3 and 4. No resident had fever or signs of infection. 6. Stat sputum culture will be done on Resident 5/17/19. 7. The shower that was used by Resident #409 was disinfected with the Xenex robot on 5/16/19 and 5/17/19. The Xenex robot had the use of a laser light to disinfect surfaces. Unit 3 lobby and room [ROOM NUMBER] had been disinfected by the Xenex robot on 5/17/19 followed by surface cleaning. 8. All current and future residents with isolation precautions will be assigned to rooms that have private showers. 9. Resident #409 was asked to remain in his room at all times unless he is donning PPE. The Social Worker and VP Clinical Nurse spoke with Resident #409 on 5/16/17(see progress note). All rooms have individual units, so the same air takes and returns in each room. Resident #409 requests that we don't close the door as it makes him anxious. When any resident comes off isolation going forward, ES staff will change the air conditioner filter. 10. We will not admit any new residents into the facility until the IJ is removed. 11. A more in-depth training on Infection Control will be planned and implemented as soon as possible. Additional Elements: Tracking and mapping infections - The facility had a system as part of the QAPI documentation log to identify type of infection, unit location, and room location. In addition to review, monthly, infections will be discussed in our IDT at risk meetings that are held on a weekly basis. We will incorporate the mapping of infections for the weekly IDT meeting to identify trends more quickly. Communicating Isolation Precautions - Upon admission or when an order is received for a long-term resident, the admitting nurse or charge nurse will enter the information to include type of infection and type of precaution in the Special Instructions section of the PCC dashboard. This information can be seen by anyone with PCC access including nursing staff, food service, housekeeping supervisor, therapy, and environmental services. The charge nurse will then put the appropriate signage based on type of infection on the resident door and place the PPE cart outside of the room. The charge nurse will also inform the resident and family members of the type of precaution and why isolation is required. In the daily, stand up meeting that were held every morning Monday through Friday, the interdisciplinary team will discuss which residents are on isolation during the risk management part of the meeting. Finally, we are currently revised our isolation signage for the resident rooms to both English and Spanish. On 5/17/19 the Survey Team confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy. Interviews were conducted with 3 RN's, 6 LVN's, 12 CNA's, 4 Med Aides, 7 Food Service Staff, 1 Activity Director, 3 Housekeeping Staff, 1 Laundry Staff, and 8 Therapy Staff. Interviews revealed that facility staff were able to identify the procedure to follow when a resident is on isolation precautions. Interviews revealed that staff were able to identify the process for identifying residents on isolation precautions, PPE used for different types of isolation precautions, and communication between staff members when a resident was identified to be on isolation precaution. An in-service dated 5/16/19-5/17/19 concerning Infection Control policy and procedures was reviewed and contained 53 signatures. On 5/17/19 the Immediate Jeopardy was removed, however, the facility remained out of compliance at the scope of widespread and severity potential for actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. 6. Laundry Room did not have the doors closed on the clean laundry side. 7. There were lateral plastic slats missing from the barrier between dirty and clean 8. The negative air in the dirty area of the laundry room was not on. 9. The laundry staff folded clean linen sheets by tucking them under their chin and dropping the clean sheets on the floor to fold them. 10. Water dripped off overhead from the air conditioning duct work into a yellow barrel located in the clean linen storage area. Observations conducted during Environmental rounds on 05/17/19 from 12:49 pm to 1:25 pm and accompanied with Laundry Attendant Y, revealed the doors to the clean laundry area were wide open, there were 3 to 4 lateral plastic slats missing from the plastic divider between the clean and dirty areas, the negative air in the dirty area of the laundry room was not on, laundry staff folding sheets tucking them under their chin and dropping the sheets on the floor to fold the clean sheets and water dripping off overhead from the air conditioning duct work into a yellow barrel located in the clean linen storage area. Interview with Laundry Attendant Y on 05/17/19 at 12:49 pm, confirmed the doors to the clean laundry area were wide open. Continued interview with Laundry Attendant Y at 12:52 pm confirmed there were 3 or 4 lateral slats missing from the plastic barrier between the clean and dirty areas and at 12:55 pm confirmed the negative air pressure for the dirty laundry area was not working or on. Continued interview with Laundry Attendant Y, at 1:05 pm confirmed the other 2 Laundry Attendants U and AA were placing the sheets under their chins and dropping the sheets to the floor as they folded the sheets. Further interview with Attendant Y, confirmed there was a sign on the outside of the clean laundry doors stating, Keep Door Closed at All Times. Attendant Y at 1:26 pm also confirmed there was a yellow trash can in the clean laundry storage area catching water from overhead from the air conditioning duct work and had been dripping over a week. Interview with Maintenance Supervisor Z on 05/17/19 at 1:00 pm revealed at entrance into the dirty laundry area and confirmed the negative air pressure was not working or on and stated he would look into the problem. On 05/17/19 at 1:50 pm Maintenance Supervisor Z stated he had discovered the negative air had been turned off.

Based on observation, interview and record review, the facility failed to ensure the environment was free of hazards for 5 of 5 resident rooms (# 18; #26; #27; #28; and #29) in addition to 8 unlocked empty rooms in Unit 7 checked for water temperatures in that: Observation on 3/31/15 at 10:50 a.m. revealed room E-10 was empty and the water temperature was 135.5 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 10:54 a.m. revealed room E-11 was empty and the water temperature was 131.6 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 10:56 a.m. room E-18 was empty and the water temperature was 137.5 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 10:58 a.m. revealed room E-23 was empty and the water temperature was 135.3 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 11:00 a.m. revealed room E-25 was empty and the water temperature was 134.1 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 11:15 a.m. revealed room E-2 was empty and the water temperature was 130.1 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and MA F acknowledged the temperature. Observation on 3/31/15 at 11:24 a.m. revealed room E-5 was empty and the water temperature was 131.9 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and MA F acknowledged the temperature. Observation on 3/31/15 at 11:27 a.m. revealed room E-24 was empty and the water temperature was 135.1 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and MA F acknowledged the temperature. Observation on 3/31/15 at 11:49 a.m. revealed the water temperature in Resident # 18's room was 136.4 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Observation on 3/31/15 at 11:45 a.m. revealed the water temperature in Resident #26 ' s room was 128.9 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Observation on 3/31/15 at 11:46 a.m. revealed the water temperature in Resident # 27 ' s room was 130.1 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Observation on 3/31/15 at 11:47 a.m. revealed the water temperature in Resident # 28's room was 135.5 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Observation on 3/31/15 at 11:48 a.m. revealed the water temperature in Resident # 29's room was 132.8 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. This deficient practice resulted in an IJ (Immediate Jeopardy) on 3/31/15. While the IJ was removed on 3/31/15, the facility remained out of compliance at the level for potential for more than minimal harm at a pattern, due to Maintenance Director not completing in-service training to all Maintenance staff to reliably control resident-use hot water that could result in a resident being scalded by hot water. This deficient practice could affect 5 residents and result in a resident being scalded by hot water. Findings include: A. During an interview conducted on 3/31/15 at 10:58 a.m. with Resident #18, he was confused and asked where his white car was. Observation on 3/31/15 at 11:49 a.m. revealed the water temperature in Resident # 18's bedroom sink was 136.4 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Record review of Resident #18's undated Admission Record sheet revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].# 18's MDS dated [DATE] revealed a cognitive score of 3 (Severe impairment for task of daily living). Resident #18 used a wheelchair for mobility. B. Observation on 3/31/15 at 11:45 a.m. revealed the water temperature in Resident #26 ' s bedroom sink was 128.9 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Record review of Resident #26's Admission Record sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident # 23 ' s MDS dated [DATE] revealed a cognitive score of 5 (Severe impairment for task of daily living). Resident #26 was used a wheelchair for mobility. C. Observation on 3/31/15 at 11:46 a.m. revealed the water temperature in Resident # 27 ' s bedroom sink was 130.1 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Record review of Resident #27's Admission Record sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident # 27 ' s MDS dated [DATE] revealed a cognitive score of 5 (Severe impairment for tasks of daily living). Resident #27 was used a wheelchair for mobility. D. Observation on 3/31/15 at 11:47 a.m. revealed the water temperature in Resident # 28's bedroom sink was 135.5 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Record review of Resident #28's Admission Record sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident # 28 ' s MDS dated [DATE] revealed a cognitive score of 7 (Severe impairment for task of daily living). Resident #28 was used a wheelchair for mobility. E. During an interview conducted on 3/31/15 at 10:50 a.m. with Resident #29 in her room while sitting in her wheelchair, Resident #29 was confused and offered no comments. Observation on 3/31/15 at 11:48 a.m. revealed the water temperature in Resident # 29's bedroom sink was 132.8 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer and LVG G acknowledged the temperature. Record review of Resident #29's Admission Record sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident # 29 ' s MDS dated [DATE] revealed a cognitive score of 3 (Severe impairment for task of daily living). Resident #29 was used a wheelchair for mobility. Observation on 3/31/15 at 10:50 a.m. revealed room E-10 was empty and the water temperature was 135.5 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 10:54 a.m. revealed room E-11 was empty and the water temperature was 131.6 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 10:56 a.m. room E-18 was empty and the water temperature was 137.5 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 10:58 a.m. revealed room E-23 was empty and the water temperature was 135.3 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 11:00 a.m. revealed room E-25 was empty and the water temperature was 134.1 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 11:15 a.m. revealed room E-2 was empty and the water temperature was 130.1 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 1:24 p.m. revealed room E-5 was empty and the water temperature was 131.9 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 11:27 a.m. revealed room E-24 was empty and the water temperature was 135.1 degrees Fahrenheit. The water temperature was taken with the surveyor's thermometer. Observations made on 3/31/15 from 10:50 a.m. through 5:45 p.m. did not reveal residents in Unit 7 wandering into rooms. During an interview conducted on 3/31/15 at 11:00 a.m. with LVN G she confirmed the water temperatures in Unit Seven were high and said she would call in a work order to have Maintenance check the temperatures. During an interview conducted on 3/31/15 at 11:54 a.m. with Housekeeper L she said she had noticed that the water had been really hot for about three days. During an interview conducted on 3/31/15 at 1:00 p.m. with LVN G she confirmed that Residents # 18, #26, #27, #28, and #29 had dementia and or confusion like symptoms and were at risk of getting water burn injuries if left unsupervised as these resident had mobility skills in which they could wander in their wheelchairs into any bedroom on that unit and turn on the hot water. During an interview conducted on 3/31/15 at 1:50 p.m. with MA F she said she noticed that the water had been hot in the last three days but did not know if Maintenance had been called to check. During an interview conducted on 3/31/15 at 1:57 p.m. with CNA H she said she had noticed and other staff had commented that the water temperatures had been hot in the last few days and she thought Maintenance had been called to check but she was not sure. During an interview conducted on 3/31/15 at 12:35 p.m. with the Maintenance Director, he said that the water temperature should range between 100 to 110 degrees Fahrenheit. The Maintenance Director said the water temperatures were checked once a week in random rooms of each floor and that the water temperatures for Unit Seven had been taken last Thursday (3/26/15) or Friday (3/27/15). The Maintenance Director said that if the temperatures were above the 110 degree range he would not be surprised because the boiler for this floor also provided hot water for the Assisted Living on the bottom floor of Unit Seven. The Maintenance Director said there were no written logs to review the results of water temperature checks conducted by the Maintenance Tech. The Maintenance Director said he had not received any work orders today (3/31/15) to check water temperature in Unit Seven. The Maintenance Director said he had a written procedure in place to log water temperatures in a sheet but that he was not using it. The Maintenance Director said staff on Unit Seven had not been informed of the water temperatures being hot. During an interview conducted on 3/31/15 at 12:45 p.m. with Maintenance Tech (Staff J), he said he checked water temperatures once a week on Thursday and Friday. The Maintenance Tech said if the water temperature was out of range (higher than 110) he would write down and report it to the Maintenance Director. The Maintenance Tech said the water temperature for Unit Seven was not supposed to be higher than 110 degrees Fahrenheit. The Maintenance Tech said he could not recall if the water temperatures were out of range when he checked them the week before. The Maintenance Tech said he had not received any complaints from staff or work orders for water temperatures being hot on Unit Seven. The Maintenance Tech said that at 9:30 a.m. today (3/31/15) he got a call from the Maintenance Director to go to the boiler room and adjust the water temperature for Unit Seven from 120 degrees Fahrenheit to 110 degrees because the, "State," was here. The Maintenance Tech said that staff on Unit Seven had not been informed of the water temperatures being hot. Record review on 3/31/15 of the, " Water Temperature Testing Procedure, " dated 6//3/13 revealed, "Temperature acceptable range is between 100 and 110 degrees." Item #4 revealed, "If temperature is out of range, make the necessary adjustments on the controller, document the adjustment made, and repeat the water temperature procedure as needed until the water is within acceptable range. Write adjusted temperature on Water Temperature Log Sheet." During an interview with the Facility Administrator conducted on 3/31/15 at 2:30 p.m. he said he was made aware of the hot water temperature on Unit Seven being out of range but did not know the status. The Administrator was notified of an Immediate Jeopardy on 3/31/15 at 2:30 p.m. The Plan of Removal provided by the facility included: "Action plan to assure proper water temperatures on Unit 7." 1. Water temperatures will be checked daily by maintenance. 2. Maintenance will keep a log (sample attached) of the daily water temperature check. 3. If water is above the required high limit of 110, the hot water will be turned off temporarily as hot water is vented out of the tank, and cooler water is added. The nursing staff on the unit will be advised that the water temperatures are out of range. 4. Water temperatures will be adjusted until correct temperatures are reached at the resident room faucets. 5. Oriented resident will be asked to refrain from using hot water, and demented residents will be monitored to assure they don ' t use the hot water while it is being adjusted. 6. When adjustments bring water temperatures to the proper temperature, residents will be notified that use of hot water is permitted. 7. The log will be turned into the administrator daily for monitoring. 8. Future issues with water temperatures will be brought to the attention of the QAPI committee for follow-up. 9. All maintenance personnel will receive in-service training on the above procedures, and how to properly check, log and adjust water temperatures on 3/31/15. The plan of removal was verified through interviews with the Administrator and the Maintenance Director on 3/31/15 and observations of the water temperatures as follow: Observation made on 3/31/15 at 1:10 p.m. revealed the hot water temperature gauge in the boiler room of Unit Seven was set at 110 degrees. Observation on 3/31/15 at 5:45 p.m. revealed the temperature in Resident # 18's room was 106.6. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 5:53 p.m. revealed the temperature in Resident # 26's room was 104.3. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 5:51 p.m. revealed the temperature in Resident # 27's room was 102.6. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 5:48 p.m. revealed the temperature in Resident # 28's room was 103.5. The water temperature was taken with the surveyor's thermometer. Observation on 3/31/15 at 5:46 p.m. revealed the temperature in Resident # 29's room was 105.1. The water temperature was taken with the surveyor's thermometer. The Plan of Removal was accepted on 3/31/15 at 5:10 p.m. The IJ was removed and the Administrator was notified of the removal on 3/31/15 at 5:10 p.m. While the IJ was removed, the facility remained out of compliance at a level for more than minimal harm at a pattern, due to the in-services of staff to reliably control resident-use of hot water remained incomplete. A census report dated 3/31/15 provided by the Facility Administrator revealed a census of 18 residents in Unit Seven.