Every finding on record at Mountain Villa Nursing Home

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two residents (Residents #5, and #8) of seven residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #5 to address residents' blood thinner medication prescription, Eliquis. The facility failed to have a comprehensive person-centered care plan for Resident #8 to address residents' diabetes diagnosis. These failures could affect residents and put them at risk for not receiving care and services to meet their needs.Findings Include:Resident #5 Record review of Resident # 5's admission record dated 12/04/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #5's history and physical dated 09/17/2025 revealed diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (hearts blood vessels are getting clogged with plaque, not causing chest pain). Record review of Resident #5's annual MDS dated [DATE] revealed a BIMS of 04 indicating severe cognitive impairment. Section N- Medications accounted for anticoagulant medication. Record review of Resident #5's medication administration record for December 2025 revealed Eliquis Oral Tablet2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for BLE arterial occlusion (a blockage in an artery on both lower extremities.) -Start Date- 02/29/2024. Record review of Resident #5's order summary report dated 12/04/2025 revealed Eliquis Oral Tablet2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for BLE arterial occlusion (a blockage in an artery on both lower extremities) -Start Date- 02/29/2024.Record review of Resident #5's care plan revised on 09/03/2024 revealed the care plan did not address the resident's blood thinner medication prescription. Resident #8 Record review of Resident #8's admission record dated 12/04/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #8's history and physical dated 12/06/2024 revealed a diagnosis of diabetes mellites type II. Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS of 15 indicating intact cognitive function. Record review of Resident #8's care plan revised on 09/08/2025 revealed the care plan did not address the resident's diagnosis of diabetes. In an interview on 12/04/2025 at 11:05a.m., with the DON revealed that the purpose of a care plan was to detail how to take care of a resident and what their needs were. She stated that MDS nurse was the one who was responsible for creating the care plans and for revising them quarterly. She stated that not having certain medications and diagnosis in the care plan could affect resident care by the staff not being aware of certain care that the resident needs. She stated she could not remember the last Inservice that was done regarding care plans. She stated that the MDS nurse received training upon hire, and she believes that the MDS coordinator would be the one to oversee that she was completing them. In an interview on 12/04/2025 at 1:22 p.m., with Administrator revealed that the purpose of a care plan was to detail the needs of the resident and to let staff know how to care for the resident. He stated that the diabetes diagnosis along with medications such as anticoagulants should have been care planned because it was pertinent to the care of the resident. He stated that the MDS nurse was responsible for ensuring that the care plans were updated with all pertinent information. She updates them quarterly and as needed. He stated that there had not been any in-services done pertaining to care plans. He stated that she was trained on how to complete the MDS upon hire and she was trained by MDS coordinator. In an interview on 12/04/2025 at 1:34 P.M. with MDS nurse revealed that the care plan was an outline on what care the patient needed. She stated that a diagnosis of diabetes should be in the care plan, and medications such as blood thinners should be included in the care plan, because of the risk of bleeding that could cause harm to the resident. She stated that she revised the care plans every 3 months and as needed and that she was responsible for updating the care plans with pertinent information. She stated that floor nurses were also responsible for letting her know any updates. She stated that there has not been any Inservice regarding care plans. Review of facility policy titled Resident Assessment and Care Planning- Care Plans revised 08/2011 read in part 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 or services to the resident.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 1 of 6 facility staff (LVN C) reviewed for trainings consistent with their expected roles, in that; -The facility failed to provide LVN C with training consistent with their expected roles. This failure could place residents at risk of accidents with potential harm due to staff not having up to date training. Findings included: Review of LVN C's personal record revealed annual training by the facility that did not include evidence of training consistent with their expected roles to include Compliance and Ethics, Abuse, Neglect and Exploitation, and Restraint Reduction.In an Interview and Record Review on 12/04/2025 at 2:30 pm with HR personnel revealed that LVN C's last annual trainings for compliance and ethics, restraint reduction, abuse, neglect and exploitation were last completed in September 2018. She stated that LVN C was a nightshift nurse. She stated that even if staff are nightshift, all staff to include nurses and CNAs were still required to fulfil the annual trainings. She stated to refer to LVN C's direct supervisor for further information on why this was not completed. She stated that usually, all the staff complete the annual trainings together at one time. In an interview on 12/04/2025 at 2:40 pm with DON revealed that LVN C was a nightshift nurse and this was most likely the reason that the trainings were not done. She stated that trainings for night shift nurses were left for them to read and sign. She stated that she was responsible for ensuring that the nursing staff were completing the annual trainings by reviewing who has signed the sheets and who had yet to. She stated that it was important for staff to be up to date on trainings, and depending on what the training was, it could have an effect on the residents' care. In an interview on 12/04/2025 at 2:47 pm with Administrator revealed that he was responsible for ensuring that the staff were up to date with annual trainings. He stated that all staff were required to complete annual trainings regardless the shift they work, but that nightshift nurses were a little harder to get a hold of. He stated that staff not being up to date on trainings such as restraint reduction and abuse and neglect could lead to the staff not knowing how to properly proceed in an event of needing to restrain or identifying abuse and neglect. Review of facility policy titled Staff Development Program revised December 2009 read in part . All personnel must participate in initial orientation and regularly scheduled in-service training classes.

Based on 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; and failed to have an established system in place for accurate reconciliation of all controlled drugs for 1 (East wing) of 2 medication carts that had residents with orders for controlled substances.The facility failed to ensure Licensed staff signed the form after counting and verifying that all controlled substances in the East Wing medication cart had been accounted for with the on-coming and off-going nurses on 12/03/25.This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. Record review and interview with LVN D of the facility's Controlled Substance Shift Change Audit Record on the East Wing's Medication Cart, dated 12/03/25, observed at 11:23 AM revealed one signature notated for shift change at 2:00 PM. LVN D stated she signed it at the 2:00 PM shift change but could not explain why it was signed ahead of time.In an interview on 12/04/25 at 11:19 AM with the DON, she stated that nurses were responsible for doing the narcotic count and signing during the change of shift. She stated nurses were only to sign during the change of shift when the count was completed, and the risk for signing ahead of time would include drug diversion which can lead to the resident not having access to their medications. The DON was unable to recall the last in-service regarding the narcotic count per policy. She stated she was responsible for monitoring the count sheet, which she did up to twice weekly.In an interview on 12/04/25 at 1:18 PM with RN A, she stated the narcotic count sheet was for nurses to ensure accuracy of medications counted during shift change. She stated that the DON was responsible for auditing the narcotic sheet as often as possible. She stated that the nurse signing the count sheet ahead of time could cause the residents to not have their medications available to them because the nurses completing the narcotic count were not counting or signing off correctly. She stated another risk was drug diversion. She was unable to recall the last in service.Record review of the facility's policy Medication Storage: Controlled Medication Storage, dated 2007, read in part: At each shift change or when keys are rendered, a physical inventory of all Schedule II controlled medications is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for one (medication aide's medication cart) of two medications carts reviewed.The Medication Aide B failed to ensure to update label Resident #31's medication Sertraline 100 MG on 12/03/25 with the current dosage instructions to Give 1 tablet by mouth one time a day, to give 25 MG tablet for total dose of 125 MG.This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications.Record review of Resident #31's face sheet dated 12/03/25, revealed a [AGE] year-old male with an admission date 02/18/2022.Record review of Resident #31's history and physical, dated 09/10/25, revealed a medical history of Anxiety (a mental health condition characterized by excessive fear and worry that can interfere with everyday life), and Major Depressive Disorder (mental health condition characterized by a constant feeling of sadness or loss of interest in activities enjoyed by the person affected).Record review of Resident #31's quarterly MDS dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment.Record review of Resident #31's Care Plan revealed the resident used the antidepressant Sertraline related to depression and anxiety. The interventions included for nursing staff to administer Sertraline as ordered by the physician.Record review of Resident #31's Order Summary Report dated 12/03/25, revealed a physician order of Sertraline 100 MG Give 1 tablet by mouth one time a day, to give 25 MG tablet for total dose of 125 MG. Record review of Resident #31's MAR for 12/2025, dated 12/03/25, confirmed resident had received 125 MG per current physician order.In an observation on 12/03/25 at 09:29 AM at the [NAME] Wing's Medication Aide B's Medication cart, Resident #31's medication, Sertraline 100 MG was observed with instructions, to give one tablet by mouth one time a day with 50 mg tablet for total dose of 150 MG. In an interview on 12/04/25 at 11:11 AM with Medication Aide B, she stated medication aides and nursing staff were responsible for updating the medications instructions as observed on the Electronic Medication Administration Record (EMAR). Medication Aide B stated that she was trained to first notify the floor nurse when the blister packet's administration instructions, and the instructions of the resident's EMAR do not match. She stated the nurse was to then reconcile the medications. She stated she was trained to add the label which notated for staff to refer to the EMAR instructions, as the EMAR reflected the most current physician orders. She stated she would audit her medication cart one to two times a week, and she believed the nurses also audit medication carts but was not sure how often. She stated that the orders of the EMAR were always followed to ensure residents get the correct medication. She stated she failed to update the medication instructions label this past Monday 12/01/25, because she got distracted with other job duties. She stated she was unable to recall the last in-service regarding medication labeling.In an interview on 12/04/2025 at 11:24 AM with the DON, she stated the medication aides were responsible for updating medication blister packets to reflect the EMAR administration instructions. She stated there was a red sticker that noted for staff administering medications to refer to the resident's EMAR, to ensure correct dosage per the physician's order. She stated that the risks of not updating medication administration instructions included overdosing or underdosing the residents. She stated medication aides audit their medication carts weekly, and the nurse audits once every couple of weeks. She was unable to provide a timeframe. The DON was unable to recall the last in-service. She stated she was responsible for ensuring medications were updated.Record review of the facility's policy titled Storage of Medication, dated 2007, read in part: Medication storage conditions are monitored on a regular basis as a random quality assurance check. As problems are identified, recommendations are made for corrective action to be taken.

Based on, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans. -The facility failed to ensure Resident #1 's pacemaker was addressed on her care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and could result in injury and a decline in physical well-being. Findings included. Review of Resident #1 face sheet, dated 03/19/2025, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of presence of cardiac pacemaker. Review of Resident #1's Quartely MDS assessment, dated 01/22/2025, reflected Resident #1 had a Brief interview for mental status score of 04 indicating severe cognitive impairment. Presence of pacemaker was listed under her diagnoses. Review of Resident # 1's comprehensive Care plan dated 3/1/25 did not reflect anything relating to her pacemaker. Interview with LVN A on 3/19/25 at 1:20 p.m. revealed that the purpose of the care plan was to make anyone aware of changes and details what kind of care the resident needs. She stated that she had not reviewed the care plan for the resident, and she was not aware that her pacemaker was not on the care plan. She stated that she is not a part of care plan meetings, and if there was a change to any resident's care plan, staff is notified via the DON and ADON verbally in meetings and in-services. She stated that she looked at residents' orders to see if anything changed throughout the day. The risk of the pacemaker not being care planned included missed communication and missed potential changes to care. Interview on 3/19/25 at 1:43 p.m. with the DON , revealed that whatever care area was triggered on the MDS would be on the care plan,. She stated if it was not triggered, then it would not show up on the care plan. She stated that nurses had to use their nursing judgment when it came to caring for a resident with a pacemaker. She stated that the nurses would report low pulse to Doctor or NP, monitor for dizziness or fainting. She stated that CNAs do not read care plans, because they did not have the time to do so. She stated that she and ADON would inform them and staff nurses of resident care plan, and the care that residents needed. Interview with ADON nurse on 3/19/25 at 2:07 p.m. revealed that the pacemaker was not included in care plan because MDS did not trigger that care area. She stated that Resident #1's pacemaker should have been included in the care plan to ensure continuity of care and prevent the resident going to hospital. She stated that any changes to resident care was verbally told to staff (nurses and CNAs) via meetings and in-services. Review of the facility's policy entitled Care Plans - Comprehensive revised December 2010 read in part, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident.The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS .

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 3 (CNA A) staff reviewed for EMR. The facility did not have CNA A's EMR on file upon hire. This failure could place residents at risk of abuse, neglect, and misappropriation of property. Findings included: Record review of Abuse and Neglect policy (not dated) read in part All personnel will be screened before hiring criminal history record, background checks, and reference. The licensing board will ne contacted for all licensed personnel to determine if any sanctions have been assessed against the applicant's license. In addition, all nurse aides conduct will be verified through employee misconduct registry. Record review of CNA A's employee files revealed her hire date was 07/19/24. Record review of CNA A's criminal background dated 07/19/24 revealed no findings. Record review of CNA A's employee file revealed no EMR was noted. Interview on 11/18/24 at 11:18 am, the Secretary stated she was the one responsible for running EMR's upon hire and the Administrator would be the one to follow up to ensure it was completed and a copy was placed in the employee files. The Secretary stated she had run CNA A's EMR but she could not find it on her file. The Secretary stated copies of EMR were required to be filed in the employee files and failure to do so, the facility would not be able to provide copy to verify the EMR was completed. The Secretary stated the DON and Administrator would be unable for interview due to a family emergency.

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 5 (04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; 06/08/2024) of 91 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of facility's Direct Care Staff Daily Report from 04/01/2024 to 06/30/2024 revealed on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024 there was no evidence of RN coverage. During an interview on 9/12/2024 at 3:15 PM, the DON stated her expectation was to have RN coverage daily. The DON stated she was on call on weekends and can be contacted when there was not a RN working. The DON stated they have a RN that worked on the weekends and then her and the MDS Coordinator work Monday and Friday. The DON stated the MDS Coordinator filled in on the weekends when needed. The DON stated if there were dates on the weekends that were reported with no RN coverage, she did not work those weekend dates, but she would have been available by phone to come to pronounce if a resident had passed away. The DON stated she did not feel there was an effect to residents when there was no RN coverage. The DON stated what led to failure was not being able to hire additional RNs. During an interview on 9/12/2024 at 3:45 PM, the ADMN stated his expectation was to have 8 hours of RN coverage 7 days per week. The ADMN stated the DON was responsible for ensuring there were 8 hours of RN coverage daily. The ADMN stated the effect on residents was the discontinuity of care. The ADMN did not have a response to what led to the failure of not having 8 hours of RN coverage. Record review of facility policy titled; RN Coverage dated 06/26/24 revealed: It is the policy of facility to provide 7-day RN coverage.

Based on observations, interviews, and record review, the facility failed to ensure the menu was followed for 3 of 6 (Resident #2, Resident #25, and Resident #33) residents who received a pureed meal reviewed during the lunch meals served reviewed for food and nutrition services. The facility failed to ensure residents, receiving a puree texture diet, were provided the food according to the menu, included a dinner roll on 09/10/2024 and a dinner roll and ice cream on 09/11/2024. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. The findings included: Resident #2 Record review of Resident # 2's Quarterly MDS dated [DATE] revealed an [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Non-Alzheimer's Dementia; Section K- Swallowing/Nutritional Status Resident #2 had a mechanically altered diet. Record review of Resident #2's Care Plan dated 08/07/2024 revealed: Focus-Nutrition: The resident had recent weight loss during hospitalization . Goal- The resident will maintain adequate nutritional status. Interventions- Provide and serve diet as ordered. Record Review of Resident #2's orders dated 06/30/2024 revealed High calorie diet, Pureed texture, regular consistency. Resident #25 Record review of Resident #25's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 10 (moderate cognitive impairment); Section I-Active Diagnosis with following diagnosis of non-Alzheimer dementia; Section K- Swallowing/Nutritional Status Resident #25 had a mechanically altered diet. Record review of Resident #25's Care Plan date 06/19/2024 revealed: Focus-Nutritional Status: the resident had a nutritional problem poor intake. Goal-The resident will maintain adequate nutritional status through review date. Record Review of #25's orders dated 04/03/2024 revealed High calorie diet, Pureed texture, regular consistency. Resident #33 Record review of Resident # 33's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Non-Alzheimer's Dementia; Section K- Swallowing/Nutritional Status Resident #2 had a mechanically altered diet. Record review of Resident #33's Care Plan dated 08/27/2024 revealed: Focus-Nutrition: The resident had recent weight loss during hospitalization . Goal- The resident will maintain adequate nutritional status. Interventions- Provide and serve diet as ordered. Record Review of #33's orders dated 08/23/2024 revealed High calorie diet, Pureed texture, regular consistency. Record review of facility menu week 3 dated 2024 revealed: On Tuesday September 10th, 2024, Lunch included a dinner roll. On Wednesday September 11th, 2024, Lunch included a dinner roll and Ice Cream. During observation on 09/10/2024 at 11:30 AM, the bread was not provided on the pureed diet trays . During an observation and interview on 09/11/2024 at 11:34 AM, the bread was not provided on the pureed diet trays. CNA G stated she felt all residents should have been provided with what was offered on the menu. CNA G asked Resident #33 if she would like to have bread, she stated yes she would. During an interview on 09/12/2024 at 11:57 AM, the ADMN stated the pureed diet came directly from the main menu and did not know if there was a policy for that exact scenario. He stated if there were missing items on the pureed trays, there could be decreased nutritional value for the resident if not replaced appropriately. The ADMN stated the DM monitored the resident diets as well as the Dietician. He stated the residents should have been getting their bread, so they can get their nutritional value of the carbs, and it was an oversight of the DM. During an interview 09/12/2024 at 5:26 PM, the Dietician stated that all residents should have been served everything listed on the menu as that was how they received their balanced diet and nutritional value. She stated the residents that presented with lower cognitive abilities should still have been served what was on the menu. The Dietician stated the CNA's and nurses on the floor should have been monitoring that residents get everything listed on the menu as well as the DM. She stated that miscommunication on the Interdisciplinary Team led to the failure and her expectations were that all residents get everything listed on the menu. Record review of facility policy Therapeutic diets undated, revealed: Policy: It is the policy to serve therapeutic diets according to doctor's orders and need of the resident. Definition: A therapeutic diet is a meal plan that controls the intake of certain foods or nutrients. It is part of the treatment of a medical condition and are normally prescribed by a physician and planned by a dietician. A therapeutic diet is usually a modification of a regular diet. It is modified or tailored to fit the nutrition need of a particular person. Therapeutic diets are modified for nutrients texture, and/or food allergies or food intolerances. Reasons for therapeutic diets; To maintain nutritional status next line to restore nutritional status. To correct nutritional status. To provide extra calories for weight gain. To balance amounts of carbohydrates, fat and protein for control of diabetes. To provide a greater amount of a nutrient . To provide texture modifications due to problems with chewing and slash or swallowing .Increased fiber should come from a variety of sources including fruits, resumes, vegetables whole breads, and cereals.

Based on observations, interviews, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #3 and Resident #32) reviewed for respect and dignity. The facility failed to ensure staff treated Resident #3 and Resident #32 with respect and dignity, with staff removing residents' trays prior to being completed. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. The findings included: Resident #3 Record review of Resident #3's face sheet dated 09/12/2024 revealed an [AGE] year-old male admitted on [DATE], with the following diagnoses: Vitamin-D deficiency, type 2 diabetes, constipation, mood disturbance, and chronic kidney failure. Record review of Resident #3's Comprehensive MDS dated [DATE] revealed that Section C- Cognitive Patterns had a BIMS score of 06 (severe cognitive impairment ). Resident #32 Review of Resident #32's face sheet dated 09/12/2024 revealed a [AGE] year-old male admitted on [DATE] with the following diagnoses: type 2 diabetes, Vitamin D Deficiency, gastritis, and major depressive disorder. Record review of Resident #32's Comprehensive MDS dated [DATE] revealed that Section C- Cognitive Patterns had a BIMS score of 06 (severe cognitive impairment ). During an interview on 09/11/2024 at 2:30pm, CNA G stated she was in the dining room with CNA H at breakfast time. She stated CNA H pulled the unfinished tray from Resident #32. CNA G stated Resident #32 asked CNA H Why are you taking my tray if I'm not finished with it? CNA G stated that CNA H ignored Resident #32 and only brought him back a juice and half of a banana. CNA G stated at lunchtime, CNA H repeated her same actions, taking Resident #32's tray away from him prior to finishing, once again caused him to yell out for his food. CNA G stated she felt the resident was left hungry at the end of the day and also resulted in her 3-day suspension for taking up for a resident from the ADMN. During an interview on 09/12/24 at 10:18 AM Resident #3 stated he ate in his room. He stated staff often brought his trays and placed them on his table taking the top off without waking him up. Resident #3 stated his food would get cold and resulted in him not wanting to eat it. He stated at times staff would come in and take his tray away telling him the kitchen needed to clean the dishes before leaving at a certain time, which resulted in him not finishing his meals. Resident #3 stated that Resident #32 was his roommate and he had witnessed staff taking his food/tray away before he finished as well. He stated he had spoken to staff about this with nothing being done. During an interview on 09/12/2024 at 11:57 AM the ADMN stated he had not known of this situation prior to this day. He stated all residents should be given enough time to eat everything that was provided on their plates and felt the CNA's would not have done that . During an interview on 09/12/2024 at 5:26 PM the Dietician stated that all residents have the right to be served and as well as given ample time to eat their food on their tray. She stated if the residents were not given enough time to eat what was provided, it could cause the resident to not get the nutritional value they needed. She stated it would have been the actions of the floor staff to monitor and oversee that the residents received and were given time to eat. She stated the ADMN should have monitored meal services as well. During exit conference on 09/12/2024 at 5:45 PM the facility stated they did not have a policy. 44728

Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #2, Resident #27, Resident #28, and Resident #36) of 13 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #2's comprehensive care plan addressed Resident's code status and fall mat. The facility failed to ensure Resident #27's comprehensive care plan addressed Resident #27's code status and PASRR services. The facility failed to ensure Resident #28's comprehensive care plan was resident specific and person centered. The facility failed to ensure Resident #36's comprehensive care plan was resident specific and person centered. These failures could affect the residents by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #2 Record review of Resident #2's electronic face sheet dated 09/12/2024 revealed an [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia, anxiety disorder, hypertension (high blood pressure), and falls. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C -Cognitive Patterns BIMS score of 00, which indicated she had severe cognitive impairment. Section GG: Functional Abilities and Goals revealed Resident #2 required assistance with transfers and when out of bed did not ambulate on her own and was in wheelchair. Record review of Resident #2's physician orders dated 09/12/2024 revealed Resident #2 had a code status of DNR. Record review of Resident #2's most recent comprehensive care plan reviewed on 09/12/2024 revealed no evidence of Resident #2's code status or the use of a fall mat. During an observation on 09/10/2024 at 11:30 AM, Resident #2 was laying in her bed with the fall mat laying on the floor beside the bed. Resident #27 Record review of Resident #27's electronic face sheet dated 09/12/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: type 2 diabetes, paranoid schizophrenia , major depressive disorder, and elevated blood pressure. Record review of Resident #27's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 9, which indicated she had moderate cognitive impairment. Record review of Resident #27's physician orders dated 09/12/2024 revealed Resident #27 had a code status of DNR. Record review of Resident #27's PASRR Comprehensive Service Plan dated 11/14/2023 revealed Resident #27 received routine case management and training skills under PASRR services . Resident #28 Record review of Resident #28's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: osteoarthritis (when the cartilage that cushions and protects the ends of bones gradually wears away). Record review of Resident #28's quarterly MDS assessment dated [DATE] revealed: BIMS score of 15 meaning cognition was intact. Record review of Resident #28's comprehensive care plan last revised on 09/10/2024 revealed: Goal: Falls: the resident has had an actual fall with (SPECIFY: no injury, minor injury, serious injury) Unsteady gait Date .Interventions: The resident will have improved mood state (SPECIFY: happier, calmer appearance, no s/sx of depression, anxiety, or sadness) through the review date . Resident #36 Record review of Resident #36's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility most recently on 01/19/2024 with diagnoses to include: visual hallucinations, altered mental status, and insomnia. Record review of Resident #36's significant change MDS dated [DATE] revealed: BIMS score of 00 which indicated severe cognitive impairment. Record review of Resident #36's most recent comprehensive care plan reviewed on 09/12/2024 reviewed: Goal: ADL: The resident has an ADL self-care performance deficit r/t weakness. Intervention: BATHING/SHOWERING: The resident requires transfer assistance by (1) staff with (SPECIFY bathing/showering) 3 times a week and as necessary . During an interview on 09/11/2024 at 4:38 PM, the MDS Coordinator stated she was responsible for completing the comprehensive care plans. The MDS Coordinator state she did not think code status needed to be incorporated in the care plan because it was in the orders and there was flag on residents' electronic chart that stated code status of residents. The MDS Coordinator stated the DON was responsible to monitor the care plans. The MDS coordinator stated she did not feel the residents were affected by not having comprehensive care plans not being completed. The MDS Coordinator did not have a response to what led to the failure . During an interview on 09/12/2024 at 3:15 PM, the DON stated the MDS coordinator was responsible for completing the comprehensive care plan. The DON stated she did not feel that residents were affected by the missing information, that staff did not look at the care plans. The DON stated care plans were just more paperwork that had to be completed. The DON did not provide a reason for the failure of comprehensive care plans not being completed . Record review of facility titled, Care Plans- Comprehensive dated December 2010, revealed Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; incorporate risk factors associated with identified problems; build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Identify the professional services that are responsible for each element of care. 48883

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (CNA B and LVN D) of 4 staff observed for infection control practices. 1. The facility failed to ensure CNA B removed gloves and performed hand hygiene at the appropriate time while providing resident incontinent care. 2. The facility failed to ensure LVN D sanitized hands at appropriate times when changing gloves during wound care. 3. The facility failed to ensure LVN D sanitized rubber tip of insulin flex pen prior to applying needle to insulin flex pen during administration of insulin to resident. These failures place residents at risk for unnecessary infections while in facility. Finding included: During an observation on 09/10/2024 at 9:43 a.m., CNA B performed incontinent care. CNA B sanitized her hands and put on gloves prior to setting up supplies needed for incontinent care. She removed shirt from closet and assisted the resident to change from sweater into a shirt. She placed the sweater on the dresser. CNA B then asked the resident to stand with the walker while she lowered the resident's pants and removed the urine soiled brief. She wiped the resident front to back with a new wipe every time and disposed of the wipes into the trash. She placed a dry brief onto the resident and assisted with him pulling up the resident's pants. CNA B assisted the resident to sit back into the wheelchair. She then placed the sweater onto a hanger and hung it in the closet. She gathered up all the trash and left the resident's room with gloved hands and trash. She walked down the hall to the shower room and disposed of the trash. CNA B did not remove her gloves or perform hand hygiene until she reached the shower room with the soiled trash and disposed into the trash bin . During an observation on 09/10/2024 at 11:18 a.m., LVN D administered insulin using multi dose flex pen. LVN D performed hand hygiene, removed the lid from the used flex pen, and then placed a new needle onto the flex pen. She did not sanitize the rubber tip of the flex pen prior to applying the needle. During an interview on 09/10/2024 at 3:27 p.m., LVN D stated she had never been told to sanitize the flex pen prior to applying needle and stated the facility policy did not state to sanitize the flex pen prior to applying the needle. During an observation and interview on 09/11/2024 at 9:49 a.m., LVN D performed wound care. LVN D sanitized her hands and gathered her supplies for wound care onto a tray outside of the resident's room. She then sanitized bedside table in the resident's room with sanitizing wipe. She sat tray with wound care supplies onto bedside table and washed hands prior to applying gloves. She cleansed wound to the left ankle with saline and gauze then removed her gloves. She placed new gloves without performing hand hygiene then applied silver cream to wound bed with wooden applicator, covered wound with gauze, and secured gauze to skin with tape. She removed gloves and disposed into trash and applied new gloves without performing hand hygiene. She cleansed wound to the right ankle with saline and gauze then removed her gloves. She placed new gloves without performing hand hygiene, then applied silver cream to the wound bed with a wooden applicator, covered the wound with gauze, and secured gauze to skin with tape. She removed her gloves and disposed into trash, then washed her hands with soap and water. She carried trash out of the resident's room and placed it into the trash bin on the treatment cart and sanitized her hands again. LVN D stated she should have performed hand hygiene in between glove changes. She stated that she had been nervous due to being watched and forgot to perform hand hygiene . During an interview on 09/11/2024 at 4:23 p.m., the DON stated she expected the nurse to sanitize the insulin flex pen rubber tip prior to placing the needle onto the insulin flex pen. She stated the pharmacy would watch medication passes about once a quarter and she expected for nurses to know how to sanitize the insulin flex pen because they had a nurse's license. She stated she could not supervise nurses all the time. The DON stated she did not know why LVN D failed to sanitize the insulin flex pen and not sanitizing could cause skin infection to the resident. The DON stated she expected for nurses to follow procedure during wound care. She stated LVN D was probably nervous from being watched and forgot to follow procedure. She stated no infection risk due to gloves were a barrier and wounds had not been infected already. The DON stated she expected her staff to change gloves and perform hand hygiene after performing incontinent care and before touching clean areas in residents room including clothing. She stated she monitored staff for hand hygiene and had just had skills check off for hand hygiene either July or August of 2024. She stated she felt staff being rushed and nervous led to the failure. She stated not performing hand hygiene appropriately could cause infection. Review of the facility's policy titled Use of Hand Antiseptic dated 2008 revealed: Hand antiseptics may be used between hand washing as long as hands are not soiled. Hand antiseptics are not to take the place of hand washing. Review of facility's policy titled Policy: Flex Pen Insulin Administration with no date revealed: Pull the pen cap straight off. Wipe the rubber seal with alcohol swab. Check the liquid in the pen. Do not use if cloudy, colored, or has particles or clamps. Select a new needle. Pull off the paper tab from the outer needle shield. Push the capped needle straight on the pen and twist the needle on until it is tight. Review of facility's policy titled Incontinent Care with no date revealed: Disposable diapers are used for incontinent residents. Check every two hours. Change as necessary. Use wipes or washcloth and make sure that the resident is properly cleaned. Discard disposable diaper properly. Review of facility's policy titled Policy: Infection Control Program with no date revealed: C. Handwashing: Single most effective way to control spread of infection. 1. Wash hands in between patient care. 2. Wash hands after using bathroom. 3. Wash hands before and after feeding residents. 4. Wash hands after handling soiled material. 5. Wash hands after using gloves. D. Gloves: 1. Change gloves in between patient care. 2. Wash hands after discarding gloves. 3. Wear gloves when handling soiled materials. 4. Discard in designated containers.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled. The facility failed to ensure that persons serving food handled food properly. These failures could place residents at risk for food borne illnesses and cross-contamination. The findings included: During an observation on 09/10/2024 at 09:00 AM, the dry storage pantry had: 1. 8 oz. beneprotein powder, no received date 6 total. 2. 4 oz. individual orange juice had no received date. 3. 2 large (size unknown) bottles of ReaLemon juice. 4. 3-7.25 cans of chicken Noodle soup, no received date. During an observation on 09/10/2024 at 9:24 AM, freezer #2 had: 6-1 lb. bags of frozen mixed vegetables with no received date. During observation on 09/10/2024 at 9:27 AM the refrigerator had: 1. 7 gallons of milk had no received date. 2. 2 opened bags labeled red apples had no opened date and no received date. 3. 3 large opened clear bags of what appeared to be jalapenos were not labeled and had no received date. 4. 1 clear gallon bag, of what appeared to be lemons, had no received date. 5. 1 large clear bag of what appeared to be broccoli, had not been labeled and no received date. 6. 3 unbagged bunches of celery was in the bottom drawer of the refrigerator was unlabeled and undated. 7. 12 unbagged, bell peppers, were placed in the bottom drawer of the refrigerator and was unlabeled and undated. 8. 1 large clear bag of cucumbers, not labeled with no received date. 9. 10 heads of lettuce with no received date. 10. One large clear unlabeled and undated box of tomatoes. During an observation on 09/10/2024 at 9:37 AM, there were 2 opened bags of bread on the kitchen shelf, with no opened date or received date. During an interview on 09/10/2024 at 10:00 AM, the DM stated all products were to be dated when received to the facility, as well as labeled if taken out of the product's original boxes. He stated he did not feel it was a big deal as they use the products up fast with no dates needed. The DM stated it was his job to monitor his staff and felt they were complying. He stated there was no failure on his part . During an observation and interview on 09/12/2024 at 9:55 AM, the follow up visit to the facility kitchen revealed there were still vegetables undated in the refrigerator. The DM stated they still did not have dates because they were not in the packages and could not apply dates to the raw vegetables that were in the clear plastic bin. During an interview on 09/12/2024 at 11:52 AM, the ADMN stated all products in the facility kitchen should have had received dates and if opened and out of the original containers should have been labeled of what the product was. The ADMN stated it was the DM who monitored the process. He stated he could not say what led to the failure nor what his expectations were, as he was unfamiliar with the kitchen policies at this time . During an interview on 09/12/2024 at 5:26 PM, the Dietician stated her expectations were for all products to be labeled and dated as the policy stated . During an observation on 09/10/2024 at 9:00 AM, DA E had not performed hand hygiene and had not applied gloves prior to touching and preparing pineapple for the resident lunch service. During an interview on 09/12/24 9:45 AM, the DM stated he could not provide staff in-services for handwashing. He stated he felt the Hand Hygiene instructions posted on the walls in front of the handwashing sink provided enough information for his staff. The DM stated he monitored his staff but could not state how often or when he monitored as life was too busy. He stated if staff did not wash and sanitize their hands, that it would cause contamination with infecting the residents, which would have made them sick. He stated if they did not wash their hands it was a mistake. During an interview on 09/12/2024 at 11:48 AM, the ADMN stated it was in the policy that all staff were to wash their hands before food being prepped. He stated if staff left the kitchen, they should have washed their hands again. The ADMN stated if staff touched food without being gloved, they should have washed their hands as well, and then gloved. He stated he knew they had plenty of gloves in the kitchen. The ADMN stated in not doing so it could have led to cross contamination with the residents being sick. He stated the DM should have monitored infection control for his kitchen staff, while himself as the ADMN, monitored the DM. He stated that staff had been in-serviced and the documentation was in his office. The ADMN stated his expectations were for the staff to comply with washing their hands. He stated the failure occurred with not washing their hands as well as not and seeking more training. During an interview 09/12/2024 at 5:26 PM the Dietician stated the DM should have monitored his staff better for hand hygiene. The Dietician stated the improper training led to the failure with her expectations, for all staff to follow all policies and procedures with hand hygiene. She stated the negative impact could have been cross contamination and passed to the residents. Record Review of facility policy Food Storage from the Policy and Procedure Manual 82, dated 2008, revealed: Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared by methods designed to prevent contamination. Procedure: .7. Hands must be washed after unloading supplies and prior to handling food items. 8 . c. Food should be dated as it is placed on the shelves .15. Refrigeration: . .e. All foods should be covered, labeled and dated .16. Frozen foods: .c. Foods should be covered, labeled, and dated. Review of Texas food Establishment Rules FDA Food Code 2022: Full Document accessed 09/19/2024 revealed [NAME] et al (JFP, March 2007) found that handwashing was more likely to occur in restaurants whose food workers received food safety training, had more than one handwashing sink, and had a handwashing sink in the observed worker's sight. This suggests that improving food worker hand hygiene requires more than food safety education. Noroviruses are environmentally stable, able to survive both freezing and heating (although not thorough cooking), are resistant to many common chemical disinfectants, and can persist on surfaces for up to 2 weeks. Proper hand hygiene and exclusion of food employees exhibiting symptoms of norovirus disease (i.e., diarrhea or vomiting) are critical for norovirus control. Record review of the United States Food and Drug Administration https://www.fda.gov/food/retail-food-industryregulatory-assistance-training/program-information-manual-retail-food-protection-storage-and-handling-tomatoes accessed on 09/19/2024, revealed: Fresh-cut tomatoes and other produce have already been washed before processing and should be considered ready-to-eat with no further need for washing unless the label says otherwise. 44728

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 2 of 6 residents (Resident #28 & Resident #198) reviewed for medication errors. 1. The facility failed to ensure MA administered the correct dose of calcium and vitamin D to Resident #28 according to the physician orders. 2. The facility failed to ensure MA administered olmesartan medoxomil (for blood pressure) and amlodipine besylate (for blood pressure) to Resident #198 according to physician orders. These failures could place residents at risk of inadequate therapeutic outcomes. Findings included: Resident #28 Record review of Resident #28's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: osteoarthritis (when the cartilage that cushions and protects the ends of bones gradually wears away). Record review of Resident #28's quarterly MDS assessment dated [DATE] revealed: BIMS score of 15 meaning cognition was intact. Record review of Resident #28's comprehensive care plan last revised on 09/10/2024 revealed Resident #28 had arthritis with interventions that included to encourage adequate nutrition. Record review of Resident #28's Physician Orders revealed the following order dated 03/28/2024: Citracal Maximum Oral Tablet 315-6.25 mg-mcg (Calcium Citrate-Vitamin D) Give 2 tablet by mouth two times a day for supplement. Further review of orders revealed the following order dated 03/25/2022 May crush and cocktail medications/open capsules if appropriate for medication administration in food or liquids unless contraindicated. Record review of Resident #28's electronic September 2024 MAR revealed Citracal Maximum Oral Tablet 315-6.25 mg-mcg (Calcium Citrate-Vitamin D) Give 2 tablet by mouth two times a day for supplement. Start Date- 03/29/2024. During an observation on 09/10/2024 at 10:08 a.m., MA administered Calcium 630mg - Vitamin D 12.5mcg 2 tablets crushed and mixed with water to Resident #28. During an interview on 09/12/2024 at 9:52 a.m., MA stated she did not give the correct dose of Calcium - Vitamin D. She stated she should have only given 1 tablet instead of 2 tablets to Resident #28. She stated she gave the wrong dose because the directions in order were confusing and had half the dose of Citracal than what was available . Resident #198 Record review of Resident #198's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, pain, type 2 diabetes mellitus with diabetic chronic kidney disease (kidney disease resulting from type 2 diabetes), and malignant neoplasm of the prostate (prostate cancer). Record review of Resident #198's admission MDS assessment dated [DATE] revealed: BIMS score of 07 which indicated severe cognitive impairment. Record review of Resident #198's physician orders revealed the following order dated 09/03/2024: amlodipine besylate oral tablet 10mg. Give 1 tablet by mouth one time a day for HTN related to hypertensive heart and chronic kidney disease without heart failure. Further review of physician orders revealed the following order dated 09/03/2024: olmesartan medoxomil oral tablet 40mg. Give 1 tablet by mouth one time a day for hypertension related to hypertensive heart and chronic kidney disease without heart failure. No evidence of hold parameters observed on either of these orders. Record review of Resident #198's electronic September 2024 MAR on 09/12/2024 revealed amlodipine besylate 10mg had been held by MA on 09/10/2024 with code 5 meaning hold see progress notes. Further review of September 2024 MAR on 09/12/2024 revealed olmesartan medoxomil 40mg had been held by MA on 09/03/2024 with code 9 meaning other see progress notes, on 09/09/3034 with code 5 meaning hold see progress notes, and on 09/10/2024 with code 5 meaning hold see progress notes. Record review of Resident #198's progress notes reviewed on 09/10/2024 at 4:22 p.m. revealed no notes entered about holding amlodipine besylate and olmesartan medoxomil on 09/03/2024, 09/09/2024, or 09/10/2024. During an observation and interview on 09/10/2024 at 10:44 a.m., MA obtained Resident #198's blood pressure and it revealed a reading of 132/56. The MA went to LVN D and reported the blood pressure reading. LVN D instructed MA to not give amlodipine besylate and olmesartan medoxomil. MA gave Resident #198's medications without amlodipine besylate and olmesartan medoxomil. During an interview on 09/10/2024 at 3:27 p.m., LVN D stated she had been instructed by the NP in the past to not give blood pressure medication if the blood pressure was less than 110/60. She stated the current medication order did not have any parameters to hold medication. During a telephone interview on 09/10/2024 at 4:11 p.m., the MD stated Resident #198 was a new resident into the nursing facility. He stated he expected for his physician orders to be followed. The MD stated physician orders for blood pressure medications should have hold parameters for when the blood pressure was below 130 and the resident was of the age of Resident #198. He stated he should have been notified if his orders needed clarification. He stated no negative impact occurred from medication being held. He stated he would monitor resident's vital signs when he performed his visits by reviewing medical records and make order adjustments then as part of his process for monitoring orders. He stated he had not performed a visit for Resident #198 because he was a new resident in the facility and instructed staff to continue medication orders as written from the hospital discharge until he was able to see the resident. During an interview on 09/11/2024 at 4:23 p.m., the DON stated there were no hold parameters for Resident #198's blood pressure medications. She stated she expected for nurses to hold medications per the nurse's judgement. She stated the facility does not call the doctor often. She expected for the doctor to be notified if the staff held medication more than 2 to 3 times per the nurse's judgement. The DON stated she did not know the BON's expectation of nurses holding medications based on nurse's judgement because the BON changed their rules all the time. She stated MA's do not write progress notes and felt the code was selected by the MA because of program restrictions. She did not answer the question on who monitors that physician orders were written appropriately, but stated the order was written appropriately. She stated no negative effect occurred to resident by medications being held and stated the medications would have lowered blood pressure even more. During a follow up interview on 09/12/2024 at 9:36 a.m., the DON continued to state that the facility acted appropriately by holding the blood pressure medication without notifying the MD and no parameters specified in the order. She stated she did expect for correct doses of Calcium and Vitamin D to be administered to the resident. She stated giving the incorrect dose had no negative effect on Resident #28. She stated that pharmacy monitored the MA administering the medications quarterly and they had not found that medications were being administered incorrectly. She did not know why the incorrect dose had been administered. Record review of the facility's policy titled Medication Administration Policy with no date revealed: 1. Must use five rights: the right patient, the right drug, the right dose, the right route, and the right time to reduce risk of medication errors. 2. Must have a basic understanding of any drug that he/she is administering i.e. what the drug is intended to treat, adverse effects and contradictions, expected outcomes and usual route. 3. Must obtain vitals such as blood pressure, heart rate, blood glucose, respirations, oxygen saturation, and pain may be indicated for administration of certain medications. 4. If vital signs are not within parameter, the nurse must hold medication according to physician orders. 5. Nurses may hold doses of medications per nursing judgement if the patient is at risk of suffering from medication administration. Must notify MD of assessment findings promptly. 6. Must document in MAR. According to the Texas Board of Nursing website, https://www.bon.texas.gov/pdfs/publication_pdfs/Scope%20of%20Practice%20Decision-Making%20Model%20-%20DMM.pdf, accessed on 09/12/2024 revealed Scope of Practice Decision-Making Model dated April 2019: 2. Is the activity or intervention authorized by a valid order If there is any question about the accuracy or appropriateness of an order, clarification must be sought [Board Rule 217.11(1)(N)] According to the Texas Board of Nursing website, https://www.bon.texas.gov/rr_current/217-11.asp.html, accessed on 09/12/2024 revealed Board Rule 217.11(1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious, or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment;

Based on observations, interviews, and record review, the facility failed to accommodate residents needs and preferences and accommodation of needs, for 1 (Resident #2) of 13 residents reviewed for dignity. The facility failed to ensure Resident #2's call light was within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Record review of Resident #2's face sheet dated 09/12/2024 revealed an [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia, anxiety disorder, hypertension (high blood pressure), and falls. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C -Cognitive Patterns BIMS score of 00, which indicated she had severe cognitive impairment. Section GG: Functional Abilities and Goals revealed Resident #2 required assistance with transfers and when out of bed did not ambulate on her own and was in wheelchair. Record review of Resident #2's most recent Care plan reviewed on 09/12/2024 revealed: Be sure her call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance. During an observation on 09/10/24 at 11:30 AM, Resident #2 was laying in her bed. The call light was not within reach of Resident #2. The call light was hanging on the wall at the foot of Resident #2's bed. During an observation on 09/12/24 at 2:51 PM, Resident #2 was laying in her bed. The call light was not within reach of Resident #2. The call light was hanging on the wall at the foot of Resident #2's bed. During an interview on 09/12/2024 at 3:15 PM, the DON stated when a resident was in bed in their room, the call light should have been placed within reach of the resident. The DON stated the nursing staff and CNA's were responsible to ensure that call lights were in reach of residents. The DON stated residents might not have had their needs met if the call light was not within reach. The DON stated what led to the failure was staff forgetting to check to make sure the call light was within reach of resident when they left the room. During an interview on 09/12/2024 at 3:45 PM, the ADMN stated his expectation was that call lights be within reach of residents. The ADMN stated the DON was responsible to monitor staff to ensure call lights were within reach of residents. The ADMN stated the effect on resident's not having the call light within reach could have been resident could have fallen or not have their needs met in a timely manner. The ADMN stated staff not paying attention and/or forgetting to check call light placement could have led to failure of call light not being in reach. Record review of Call Lights not dated, revealed: Each resident will have a call light, Call light will be placed within reach of resident.

Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 2 (Resident #46 and Resident #198) of 13 residents reviewed for care plan completion. 1. The facility failed to complete Resident #46 and Resident #198's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Record review of Resident #46's face sheet dated 09/12/2024 revealed the resident was an [AGE] year-old male admitted on [DATE] with the following diagnoses: chronic kidney disease, renal dialysis, hypertension (high blood pressure), and Type 2 diabetes. Record review of Resident #46's admission MDS dated [DATE] revealed: Section C- Cognitive Patterns revealed Resident #46 had a BIMS score of 00, which indicated he had severe cognitive impairment. Record review of Resident #46's medical record revealed no evidence of the completion of a baseline care plan. Record review of Resident #198's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, pain, type 2 diabetes mellitus with diabetic chronic kidney disease (kidney disease resulting from type 2 diabetes), and malignant neoplasm of prostate (prostate cancer). Record review of Resident #198's admission MDS assessment dated [DATE] revealed: BIMS score of 07 which indication severe cognitive impairment. Record review of Resident #198's medical record revealed no evidence of the completion of a baseline care plan. During an interview on 09/11/2024 at 4:38 PM, the MDS Coordinator stated she was responsible for completing the baseline care plans and that baseline care plans were supposed to be completed within the first 24 hours of admission. The MDS Coordinator stated that what led to the failure of baseline care plans not being completed, within time frame, was that she had to work the floor sometimes and if she worked the floor over the weekend, she would take off during the week. The MDS stated when she worked the floor those duties took priority over her other duties, that was what caused the delay in completing baseline care plans. The MDS Coordinator stated she did not feel residents were affected by not having baseline care plans completed. During an interview on 09/12/2024 at 3:15 PM the DON stated the MDS coordinator was responsible for completing the baseline care plan. The DON stated she did not feel there was an effect on residents for not having a baseline care plan completed. The DON stated that staff don't look at the care plan, it was just more paperwork to complete. The DON did not provide a reason for the failure of baseline care plans not being completed. Record review of facility policy titled, Care Plans-Preliminary dated August 2006, revealed: To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. The Interdisciplinary Team will review the Attending Physician's order (e.g., dietary needs, medications, and routine treatment, etc.), and implement a nursing care plan to meet the resident's immediate care needs. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan.

Based on interview, and record review, the facility failed to implement its written polices, and procedures that prohibit abuse, neglect and exploitation for 10 of 16 staff (Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and Cook B) reviewed for neglect and abuse policies . The facility failed to conduct annual EMR/NAR screening for staff. This failure could put residents at risk of receiving services from employees who with a history of misconduct and/or were ineligible to provide services in this setting. Finding include: Record review of personnel files revealed the following staff (Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and Cook B) did not have current annual screening of the employee misconduct registry/nurse's aide registry completed: Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and Cook B. Interview on 08/09/23 at 9:52 AM with the Secretary stated she was of responsible for completing the annual EMR/NAR screenings. The Secretary stated it was mandatory to conduct annual screenings for EMR/NAR by the state. The Secretary stated the reason screenings are conducted was so staff are eligible to keep an eye on the residents and to ensure the residents are not being abused or neglected by the staff. The Secretary stated not keeping up with the annual mandatory screenings could be a risk to the residents leaving them open to abuse or neglect. The Secretary stated she keeps forgetting to do the annual screening for EMR/NAR and this years was completed on 08/08/23 for the staff. The Secretary stated the Administrator was responsible for overseeing that she was doing the annual mandatory screening. Interview on 08/09/23 at 3:55 PM the Administrator who stated that facility employees are screened for EMR/NAR upon hire and annually. The Administrator stated the purpose of screening annually was to make sure nothing had changed with any employee and that they are still eligible to work for the facility. The Administrator stated there could be a risk if screening was not done annually. The Administrator stated there was potential for abuse and neglect . Record review of the facility employees (Dietary Supervisor Date of hire 09/14/16, Activities Director Date of hire 11/14/16, CNA D Date of hire 06/08/21, CNA E Date of hire 01/14/20 , CNA F Date of hire 10/24/17, CNA H Date of hire 03/29/22, CMA K Date of hire 09/28/18, CMA L Date of hire 08/07/19, Cook B Date of hire 09/07/07). for EMR/NAR documentation revealed the EMR/NAR screening was conducted on 08/08/23. Record review of the facility abuse, and neglect policy dated 09/01/14 revealed employee misconduct registry - all personnel will go through the employee misconduct registry before hire and yearly thereafter.

Based on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards for 1 (Resident #9) of 20 residents and to ensure 7 of 10 facility rooms were safe from hazards reviewed for accident hazards. 1. The facility failed to ensure that 5 resident-use bathroom sinks had hot water temperatures below 110 degrees F and did not put residents at risk of injury. 2. The facility failed to make sure the Resident #9's fall mat was placed according to plan of care 3. The facility failed to ensure that 1 utility closet and 1 housekeeping storage room remained closed/locked due to chemicals being stored in the housekeeping room and industry equipment/pipes in the utilizes closet. These failures could place residents at risk of injury. Findings include: Water Temperatures Observation on 08/07/2023 at 9:30 AM in the resident-use bathroom between rooms 14/16 using surveyor's thermometer revealed a hot water temperature of 127 degrees F. In observation and interview on 08/07/23 beginning at 10:15 AM the Maintenance Supervisor said two of five hot water heaters supplied hot water to the resident-use bathrooms on the facility's two wings (East Hall and [NAME] Hall). He said that the hot water heater for the [NAME] Hall provided hot water for all bathrooms on the [NAME] Hall and a communal shower located near the [NAME] Hall nurse's station. He said the hot water heater located to the right of the Administrator's office provided hot water for all the bathrooms and communal shower located in the East Hall. He said three other hot water heaters provided hot water to the laundry and kitchen only. Observation by the Maintenance Supervisor and surveyor of the resident-use bathroom sink between rooms [ROOM NUMBERS] (West Hall) revealed a hot water temperature of 118 degrees F using the Maintenance Supervisor thermometer. Observation by the Maintenance Supervisor and surveyor of the sink in the bathroom next to room [ROOM NUMBER] (West Hall) revealed a hot water temperature of 118 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor said that he checked water temperatures in the resident-use bathrooms for the whole facility every week and recorded the temperatures on a written log. Observation of the hot water temperature in the sink in a communal bathroom to the left of room [ROOM NUMBER] (West Hall) revealed a water temperature of 157 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor stated that the water temperatures might be high because morning baths had been done for some time. He said that typically when the showers were in use earlier in the morning all the hot water got used up so water temperatures would go down all over the facility. Observation of the sink in the private bathroom in room [ROOM NUMBER] (West Hall) revealed that there was no hot water because the hot water valve under the sink was off. The Maintenance Supervisor opened the hot water valve, and the hot water in the sink measured 130 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor was observed turning off the hot water valve saying that the water was too hot. In observation and interview on 08/07/23 at 10:27AM with the Maintenance Supervisor the [NAME] Hall hot water heater gauge reflected a hot water temperature of 141 degrees F. Maintenance Supervisor said the water was too hot and he would have to drain the hot water heater. In observation and interview on 08/07/23 at 10:34 AM with the Maintenance Supervisor the East Hall hot water heater gauge reflected a hot water temperature of 100 degrees F. In observation on 08/07/23 at 10:42 AM with the Maintenance Supervisor of the hot water from the sink in the East Hall bathroom for room [ROOM NUMBER] revealed a hot water temperature of 130 degrees F. In an interview on 08/07/23 at 10:59 AM the ADON said she had not received any complaints about resident-use water being too hot. She said that there were no incidents of scalding or burns from hot water for the past year. She said if CNAs noticed the water was too hot the nurse would be notified, and it would be reported to the facility Administrator. She did not know if there was a schedule for Maintenance to check water temperatures in resident bathrooms. Incident reports for the past six months were requested. Record review of incident reports dated from February to August of 2023 revealed no incident reports for burns or scalding. In an interview on 08/07/23 at 11:05 AM the DON was informed of the hot water temperatures being observed in resident use areas. She stated she did not know what the top water temperature for resident use should be, but that if the water temperature was too high residents could get scalded. In an interview on 08/07/23 at 12:03 PM the Maintenance Supervisor said he was draining the hot water heater for the [NAME] Hall and would set it at 100 degrees F. He stated he would also drain the East side hot water heater since there were rooms on the East side with high water temperatures. Water temperature logs for the past six months were requested. Record review on 08/07/2023 of the facility document Weekly Hot Water Temps 2023 dated from 01/02/2023 to 05/29/2023 documented that hot water temperatures were being checked once a week in all resident rooms. The document revealed no instances when the water temperature was higher than 103 degrees F. The document noted Safe water temperature between 100 [degrees] F - 110 [degrees] F. There were no water temperatures documented for the months of June 2023, July 2023 or August of 2023. In an interview on 08/07/23 at 5:03 PM the Administrator said that around 10:00 AM the facility had lowered the temperatures on both hot water heaters to lowest setting and drained hot water from both hot water heaters. In observation on 08/07/23 beginning at 5:09 PM with the Administrator and Maintenance Supervisor observation in the resident-use sink in the bathroom between Rooms 14/16 (West Hall) revealed a hot water temperature of 126 degrees F. Observation of the resident-use sink in communal shower room for the [NAME] side revealed a hot water temperature of 137 degrees F. Observation of the resident-use sink in room [ROOM NUMBER] (East Hall) revealed a hot water temperature of 118 degrees F. In an interview on 08/07/23 at 5:28 PM the Administrator and Maintenance Supervisor said they had called a plumber to inspect and adjust hot water heaters in the morning . In an interview on 08/07/23 at 5:31 PM the ADON said excessive hot water temperatures could put residents at increased risk of scalding and burns. She said she had in-serviced all CNAs to check water temperatures on their bare skin, then have the residents also check the water temperature before using the water for resident care. Observation and interview on 08/08/2023 at 8:16 AM with the Maintenance Supervisor and the facility President (Co-owner) in the bathroom between rooms [ROOM NUMBERS] (West) revealed that the hot water temperature in the sink was 120 degrees F. The facility President stated there were several ways to adjust the hot water temperature and that water temperature at the point of use would be 4 to 6 degrees lower than the temperature showing on a hot water heater gauge. Observation and interview on 08/08/2023 at 8:26 AM with the Maintenance Supervisor, the facility President (Part Owner) and the Administrator in room [ROOM NUMBER] (East) revealed that the hot water temperature was 118 degrees F using the Maintenance Supervisor thermometer. The Administrator said that the plumber had determined that the temperature gauge on the East side water header heater was broken and stuck at 100 degrees F. He said that the East side water heater was currently set on hot. In observation and interview on 08/08/2023 at 11:22 AM a plumber and the Maintenance Supervisor were observed working on the East side water heater. The plumber said the water heater was set at low which would yield a maximum water temperature of 120 degrees. When asked he said that he had not been advised as to the acceptable temperature for hot water for the facility. He explained that the mixing valve on the water heater could be adjusted to mix hot and cold water to the desired temperature. In observation on 08/08/2023 beginning at 2:52 PM with the Maintenance Supervisor and Administrator, six resident-use bathroom sinks on the [NAME] Hall had hot water temperatures below 110 degrees F. It was observed that the resident-use bathroom sink in room [ROOM NUMBER] (East Hall) had a hot water temperature of 116 degrees F. The Administrator said that the hot water for room [ROOM NUMBER] went directly into the bathroom sink and did not pass through the water heater mixing valve. He said the occupant of room [ROOM NUMBER] wanted to stay in that room with the understanding that the hot water to the sink would be turned off. In an interview on 08/09/2023 at 8:11 AM the facility Administrator said the mixing valve on the East Hall water heater had been adjusted to lower the temperature of water delivered to resident's rooms. He did not state to what temperature the water temperature had been lowered. Record review of the undated facility policy Water Temperature documented it was the policy of the facility to maintain a water temperature suitable for the comfort of the residents in resident-use areas. It stated to check temperature in resident's room, shower and restroom. Water temperature must not be higher than 110 degrees Fahrenheit. Temperature log must be done at least once a week by maintenance. Fall Risk Resident #9's face sheet dated 08/09/23 revealed admission on 10/19/18 to the facility. Resident #9's history and physical dated 03/08/22 revealed an [AGE] year-old female diagnosed with dementia, debility (physical weakness), spondylosis (abnormal wear on the cartilage and bones of the neck (cervical vertebrae)), aspiration pneumonia, and dysphagia (difficulty swallowing). Resident #9's quarterly MDS dated [DATE] revealed ADLs for resident for bed mobility was one person assist with total dependence and transfers as total dependence with two-person assistance. Resident #9's care plan dated 02/03/23 revealed the resident was low risk for falls due to dementia and limited mobility. Place the floor mat to minimize the injury in case resident falls. Resident #9's quarterly fall risk assessment for 02/05/23 indicated resident was a high risk for falling and had a history for falling before. Resident's gait was weak and impaired. Fall risk assessment dated [DATE] revealed low risk for falling and was marked as no for history of falling . Observation on 08/09/23 at 1:16 PM revealed Resident #9 was in bed with head of bed elevated past the headboard top plane and floor mat was underneath the resident's bed. Observation on 08/09/23 at 2:13 PM in Resident #9's room. The resident's floor mat was underneath the resident's bed while resident was lying in bed. Interview on 08/09/23 at 1:20 PM RN A stated Resident #9's fall mat needed to be placed next/near the resident's bed and not underneath Resident #9's bed so if resident fell she would not get hurt. RN A stated anyone placing the resident in bed was responsible for putting the fall mat back in place next to the bed. RN A stated the risk to Resident #9 was falling possibly getting fractures because she was older and had brittle bones. Interview on 08/09/23 at 2:01 PM with the ADON. The ADON stated Resident #9 was not high risk for falls. The ADON stated Resident #9 has never had a fall during her time at the facility. The ADON stated the fall mat needed to be placed back next to the bed so if the resident fell she would not get hurt. The ADON stated Resident #9 would be at risk for injuries since the fall mat was not placed correctly. Utilities Closet & Housekeeping Storage Room Observation on 08/07/23 at 4:55 PM revealed the in the main corridor hallway in the building, the utilities closet was not closed all the way shut. By pulling the door it opened and inside was a water heater, a ladder, boiler, piping on the walls, and other large industry appliances with metal piping running down at ankle level running through the room. The utilities closet was located in a high traffic area where residents were passing by. Interview on 08/07/23 at 4:47 PM the ADON stated the utilities room needed to be secured, closed, and locked due to the water heater and other industrial equipment being housed in the room. The ADON stated it was to be closed and locked so resident would not get into the room. The ADON stated there was a risk to the residents because there was a water heater, boiler, and other appliances in the room in which the residents could have hurt themselves with. Observation on 08/07/23 at 5:03 PM revealed in the main corridor on the other side of the hallway in the building the housekeeping storage room was left open. Inside the room there were various chemicals in spray bottles and containers, brooms, mops, boxes. Interview on 08/07/23 at 5:05 PM the ADON stated the housekeeping door needed to remain closed and locked so residents don't get in. The ADON stated the risk to the residents where that they could get the chemicals risking injury. Interview on 08/08/23 at 1:25 PM with the Dietary Supervisor stated he was also in charge of the housekeeping department. The Dietary Supervisor stated the housekeeping storage room door was not supposed to be opened and unlocked. The Dietary Supervisor stated there was a risk to the resident if they got into the room if they ingested any of the chemicals. Interview on 08/08/23 at 1:45PM AM the Maintenance Supervisor stated the utilities closet needed to be closed and locked at all times. The Maintenance Supervisor stated it was a hazard for the residents because there was industrial appliances in the room and pipes were low to the ground. The Maintenance Supervisor stated if the residents had gotten into the room they could have fallen or gotten hurt. Interview on 08/09/23 at 3:55 PM with the Administrator stated the utilities closet and housekeeping storage room were to remain closed and locked. The Administrator stated they were putting locks at the top of the doors to make sure they locked and where residents were not able to reach them. The Administrator stated the residents going into the utilities or housekeeping rooms could be a risk of something dangerous happening to them. The Administrator stated the facility employees are responsible for making sure that the doors are closed and locked for the utilities and housekeeping rooms. Facility policy of accidents and supervision and falls were not obtained. Record review of the facility dietary safety awareness policy not dated revealed to keep bathroom doors and utility doors closed.

Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation/storage, in that: 1. Foods in dry store, walk in, and freezer were not dated or labeled properly. 2. Food containers and food bags were not properly sealed in the kitchen and walk-in. 3. Hot food had been placed in the refrigerator while hot. 4. A dented can was not removed from shelf rotation. 5. the dish washer temperature was not at or above 140 degrees. These failures could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 08/07/23 beginning at 8:15 AM with the Dietary Supervisor revealed in the freezer door was a bag of Chile rellenos with no expiration date noted. On the first shelf in the freezer there was a closed package of sausage not labeled, on the bottom self were (x6) closed bags of potatoes not labeled. At 8:32 AM on in the seconded freezer on the door was a closed bag of chicken nuggets not labeled, underneath on the door were French toast packages not labeled. At 8:41 AM in the refrigerator on the seconded shelve was a small metal pan labeled breakfast and not labeled correctly and very hot. The Dietary Supervisor stated the hot pan of breakfast puree was not to be in the refrigerator and needed to cool down first before being put in to the refrigerator. On the right side of the refrigerator on the top shelve was a container of orange juice not labeled correctly , an open bag of cheddar cheese slices in a zip lock bag and not labeled correctly, a zip lock bag that was not sealed properly of white cheese and not labeled correctly. At 8:45 AM across the refrigerator and freezer the shelves had a container of creamy of wheat that was open and not sealed. The Dietary Supervisor stated the creamy of wheat had to be sealed or closed to prevent cross contamination. Observation and interview on 08/07/23 at 8:50 AM in the basement revealed there was a dented can of pears in the rotation shelves. The Dietary Supervisor stated the dented can of pears should not have been placed in the rotation shelves and should have been placed in the discarded box to return to the supplier. The Dietary Supervisor stated dented cans are not used because they are contaminated, grow bacteria like e-coli and if served to residents can hurt their stomachs. All the cans on the shelve were not dated. Observation on 08/07/23 at 9:00 AM in the kitchen in the prep area were two spice containers (Lemon pepper & Black pepper) that has the lids open. The Dietary Supervisor stated the lids need to be closed to prevent bugs from going into the containers and causing contamination. Observation on 08/08/23 at 8:55 AM of the dish machine temperature gauge for the water as dishes were moving through it read 128 degrees F indicating the water was not being heated to 140 degrees F. Interview on 08/08/23 at 9:04 AM with Cook B stated she waits for cooked foods to cool down before putting them in to the refrigerator. Cook B stated the hot foods are not supposed to go into the refrigerator hot. Cook B stated if served to the residents it could hurt their stomachs. Cook B stated open foods need to be labeled correctly with date, name, and expiration date. Cook B stated the dish machine's water needed to be at 140 degrees to be able to kill the germs. Cook B stated not being at 140 degrees runs the risk of germs not being killed. Cook B stated she lets her supervisor know if there are any dented cans. Cook B stated she does not use dented cans because it can cause e-coli. Cook B stated at her house she does not use dented cans because of bacterial growth that can get you sick. Cook B stated the residents could get sick if served. Interview on 08/08/23 at 9:20 AM with the Dishwasher C stated foods need to be labeled correctly with name, date, and expiration date. Dishwasher C stated she received training with temperature, labeling, and cooking foods from her Dietary Supervisor as well as through the food handler's course. Dishwasher C stated the water in the dish machine needed to be at 140 degrees to kill the bacteria and if it was not at 140 then it would not kill the bacteria. Dishwasher C stated running dishes through the dish machine not at 140 degrees and using the dishes could get resident's sick. Dishwasher C stated if she sees dented cans, she notifies her Dietary Supervisor. Dishwasher C stated dented cans are not good to use but does not know why they are not good to use. Interview on 08/08/23 at 9:38 AM the Dietary Supervisor stated that they do not put an expiration date on foods because they know that the food will not last pass seven days. The Dietary Supervisor stated mislabeled foods that are served to residents can get them sick. The Dietary Supervisor stated dented cans cannot be used because organisms can grow inside of the can . The Dietary Supervisor stated the dish water needed to be at 140 degrees to be able to kill the bacteria and not being at that temperature could get resident's sick. Recorded review of the facility dietary policies/procedures not dated revealed food storage - open food items must be dated when opened. Open frozen foods must be dated. Use dishwashing machine to wash utensils at 140-degree temperature. Record review of the facility dietary safety awareness policy not dated revealed outdated, dented goods must be discarded. Record review of facility in-service report on diet and nutrition dated 05/12/23 revealed dietary staff were trained with the understanding the importance of nutrition care. Record review of facility in-service report for food temperatures dated 06/24/23 revealed dietary staff were trained on people review and learn to drive the correct and different kind of temperature on the food.

46998 Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #30) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #9's that reflected as needed oxygen therapy. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #30's face sheet dated 08/09/23 revealed admission on 11/02/18 and readmission on 04/20/23 to the facility. Resident #30's history and physical dated 05/03/23 revealed a [AGE] year-old female diagnosed with chronic obstructive pulmonary disease, general weakness, and dementia. Resident #30's significant change MDS dated [DATE] revealed a diagnosis of asthma/ chronic obstructive pulmonary disease, muscle weakness, and history of covid-19. Resident marked down for oxygen therapy. Resident #30's care plan dated 01/06/23 revealed resident was on oxygen therapy for poor oxygen absorption. Oxygen via nasal cannula at 2 liters per minute continuous. Resident #30's order recap dated 03/29/23 revealed supplemental oxygen at 1 liter per minute by nasal cannula as needed as tolerated to keep oxygen saturation 92% or above every shift . Interview on 08/09/23 at 2:01 PM with the ADON. The ADON stated she did not know much about care plans. The ADON stated the doctors' orders needed to match the care plan. Interview on 08/09/23 at 3:20 PM with the DON stated she completed the care plans for the residents. The DON stated she oversees that the care plans are being completed correctly. The DON stated Resident #30 had doctors' orders for oxygen as needed oxygen. The DON stated the care plans were not correct because it did not reflect the doctors' orders. The DON stated, we go by doctors' orders. Record review of the facility care planning - interdisciplinary team policy dated 2014 revealed our facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The care planning/interdisciplinary team were responsible for the review and updating of care plans. Record review of facility's using the care plan policy dated 2006 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 or services to the resident. Changes in the resident's condition must be reported to the MDS assessment coordinator so that a review of the resident's assessment and care plan can be made.

Based on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 10 residents (Resident #9) reviewed for enteral feeding. Resident #9 was on continuous feeding and while feeding. The facility failed to ensure Resident #9's head of the bed was elevated at a 45-degree angle per care plan These failures could place residents receiving enteral feedings at risk of aspiration. Findings include: Resident #9's face sheet dated 08/09/23 revealed admission on 10/19/18 to the facility. Resident #9's history and physical dated 03/08/22 revealed an [AGE] year-old female diagnosed with dementia, debility (physical weakness), aspiration pneumonia, and dysphagia (difficulty swallowing). Resident #9's care plan not dated revealed feeding tube - resident has an alteration in gastro-intestinal status with dysphagia. Avoid lying down for at least one hour after PEG (percutaneous endoscopic gastrostomy) feeding. Keep HOB (head above bed) elevated at all times. Resident #9 requires tube feeding due to dysphagia and requires/needs the HOB (head above bed) elevated 45 degrees during and thirty minutes after tube feeding. Observation on 08/08/23 at 4:30 PM of Resident #9 in bed with HOB top of mattress level with the plane of the headboard indicating level of bed was low and not at 45 degrees. Observation on 08/09/23 at 1:16 PM of Resident #9 in bed with head of bed elevated past the headboard top plane indicating 30 degrees. Interview and observation on 08/09/23 at 12:03 with RN A revealed she administered 120ml (mililter) water bolus to Resident #9 as scheduled via G-tube . Resident #9 was lying in bed with head of bed slightly elevated. When RN A completed administration of water bolus Resident #9 was left with head of the bed slightly elevated. RN A stated head of bed needed to be at about a 30-degree angle. RN A stated the head of the bed and mattress where at the same level indicating the resident was in a 30-degree angle . RN A proceeded to elevate the head of the bed to a 40-45-degree angle. RN A stated resident needed to be with the head of the bed at a higher angle to prevent aspiration at 45 degrees. Interview and observation on 08/09/23 at 1:20 PM RN A stated that earlier Resident #9 was too low in her bed and was not elevated according to doctors' orders. At 1:27 PM Resident #9 was in bed and a range scale was applied to the frame of the bed indicating 30 degrees. RN A stated that Resident #9 was not elevated correctly as she needed to be 45 degrees as per doctors' orders. RN A stated not having the resident at 45 degrees can be a risk for her. RN A stated the Resident #9 could aspirate. Record review of facility tube feeding policy not dated indicated elevate HOB (head above bed) 30-45 degrees to prevent aspiration.

Based on observation, interview and record review, the facility failed to immediately consult with resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician when she had 3 hypoglycemic episodes. After the 3rd hypoglycemic episode, Resident #1 became unresponsive and had no respirations or heart rate. Resident #1 had a DNR and was pronounced dead. This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure placed residents at risk for untimely and appropriate care leading to injury and or death. The findings included: Review of face sheet dated [DATE] documented Resident #1 was a [AGE] year-old female admitted on [DATE]. Review of the hospital History and Physical dated [DATE] documented Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE] documented Resident #1 had a BIMS score of 11, required extensive assist for ADLs and received insulin injections. Review of Order Summary Report dated [DATE] revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] Auto-injector 2 mg/ 0.85 ml inject 2 mg one time a day every Tuesday for DM II with peripheral circulatory disorders. [MEDICATION(S)] is a non-insulin medication to improve control of blood sugars in adults with type 2 diabetes. b. Novolog Solution (short-acting insulin) 100 units/ml inject 20 units subcutaneously before meals for DM II c. [MEDICATION(S)] (long-acting insulin) Max [MEDICATION(S)] pen injector 300 units/ml Inject 130 units one time a day in AM. There were no orders for checking blood sugars, parameters for holding medication or for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] Max [MEDICATION(S)] pen injector 300 units/ml Inject 130 units was administered at 8 AM on [DATE], [DATE], [DATE], [DATE]. b. Novolog Solution 100 units/ml inject 20 units subcutaneously before meals was not administered before lunch on [DATE]. It was not administered before dinner on [DATE], [DATE], [DATE] and [DATE]. The reason given on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse's notes for Resident #1 revealed the following: a. No documentation on the progress notes for the Novolog not being administered at 4:30 PM on [DATE] or [DATE]. No documentation of physician notified of the Novolog being held. b. [DATE], 3:42 AM - LVN A documented that at approximately 3:00 AM, resident (#1) was restless, took off her nasal canula, had disrobed and was clammy. Blood sugar was 52. LVN A documented placing a cold, wet washcloth over the resident's face and did a sternal rub without the resident waking enough to take any food or drink by mouth so LVN administered [MEDICATION(S)] SQ. LVN A wrote she would notify the resident's managed care provider in the morning and recheck the blood sugar. There was no documentation the physician was notified. c. [DATE], 4:29 PM, LVN B documented the Novolog 20 units was held due to Resident #1 having a blood sugar of 52. There was no documentation Resident #1's physician was notified. d. [DATE], 6:15 AM - LVN A documented at 3:55 AM Resident #1 was restless and her blood sugar was 43. Resident was repositioned in bed and sucrose was given to her orally. LVN A documented blood sugar slowly came up and documented readings of 48, 52 and 56 over the next hour and Resident #1 was responsive to command by opening eyes. LVN documented she returned to the bedside at 5:30 AM and Resident #1's blood sugar was 53. Nurse ran a damp wash cloth over resident's face and asked her to open her eyes, she did slightly open her eyes which appeared to roll in a [CONDITION(S)]-like manner, she then suddenly stopped breathing, sternum rub applied, no response, resident is DNR status. No vital signs detected, weekend RN notified. There was no documentation Resident #1's physician was notified when her blood sugar dropped and did not recover. In an interview on [DATE] at 3:30 PM, LVN B said Resident #1 was diabetic and was getting insulin. LVN B said the insulin on [DATE] was held because there were no parameters and the resident was not eating well. LVN B said when a medication is held, the nurse has to document the medication was held and notify the doctor. LVN B said [MEDICATION(S)] was administered so Resident #1's blood sugar would not drop even lower even though he did not have an order to administer it. LVN B said in hindsight the doctor should have been notified of the low blood sugar and the administration of the [MEDICATION(S)]. In a telephone interview on [DATE] at 4:12 PM, the Managed Care Provider DON said the doctor should be notified of blood sugars outside of ,d+[DATE]. The Managed Care DON said the physician needs to be notified if insulin is held and especially if [MEDICATION(S)] is given - it is a red flag that a change needs to be made; even more so if it is done a 2nd time. If the blood sugar is low an order is not needed to give [MEDICATION(S)] but the doctor has to be notified. In a telephone interview on [DATE] at 4:33 PM, Resident #1's Primary Care Physician (PCP) said he had been her physician for [AGE] years. In that time she had not had a problem with [CONDITION(S)], on the contrary she was hyperglycemic. The PCP said Resident #1 had been on the same insulin regimen for a long time without complications and the hospital physician kept her on the same regimen while she was in the hospital. The PCP said he did not give parameters for being notified of low blood sugars as the resident had stable blood sugars. The PCP said he was never contacted when Resident #1 had low blood sugars, when [MEDICATION(S)] was administered or when her blood sugars did not respond to nursing interventions. He said he should have been notified when the [MEDICATION(S)] was first given and when Resident #1 did not respond to the interventions. The PCP said the nursing staff had the whole of Saturday ([DATE]) to let him know so orders could have been changed or the resident could have been sent out to the hospital. In a telephone interview on [DATE] at 6:55 PM, LVN A said she administered [MEDICATION(S)] on Saturday ([DATE]) when Resident #1's blood sugar dropped. She said she did not call the doctor as the resident responded to the [MEDICATION(S)]. LVN A said on Sunday ([DATE]) Resident #1 could open her eyes but she could not swallow. LVN A said there was no more [MEDICATION(S)] in the emergency kit so she mixed pudding with lots of sugar and put it in her cheeks and under her tongue. LVN A said Resident #1 started to respond - she would open her eyes and squeeze her hand but her speech was garbled. LVN A said she was not sure what the facility policy was for calling for low blood sugars but said the physician should be notified for a change in condition. LVN A said she did not notify the doctor as she wanted to give the resident a chance to wake up. LVN A said after she had checked the resident's blood sugar about 5:30 AM, she suddenly stopped breathing. LVN A said she lowered the bed for CPR but checked the resident's code status and she had a DNR order. LVN A said if anything was out of the ordinary for a patient she was trained to call the family, the doctor and the weekend supervisor or DON. In a telephone interview on [DATE] at 10:16 AM, the RN Supervisor said she was in the facility on Saturday ([DATE]) during the evening shift. The RN said she gets report from the nurses on each of the residents and no one told her about Resident #1's [CONDITION(S)] or the administration of the [MEDICATION(S)]. The RN said she did not know there was any problem with Resident #1 until she was called on Sunday morning to pronounce her death. In an interview on [DATE] at 11:05 AM, the DON said the staff was trained to notify the doctor when there is a change in condition. When the DON was asked what reason LVN A gave her for not calling the doctor, the DON said it happened so quick what was she supposed to do? The DON said the facility policy and procedure was to notify the doctor of low blood sugars and staff have been trained to do that. If emergency medicine is given then staff need to call the doctor. The DON said when insulin is held, especially when [MEDICATION(S)] was given, the doctor should have been notified. The DON said with any significant change, like Resident #1, the doctor should be notified within 30 minutes. In an interview on [DATE] at 6:41 PM, the Interim NFA said he was aware of the incident with Resident #1. He said his take was that the patient was having a difficult time and the staff were trying to do their best to help this particular resident. The Interim NFA said in the process they might have missed some proper protocols that were not done. The Interim NFA said he would expect the doctor would be notified and also the facility administration. Review of Policy and Procedure for Change of Condition/Notification, undated, stated it is the policy of the facility that the physician and family be notified for significant changes. The charge nurse will document physician/family notification in the medical record or incident report. For extreme emergency the charge nurse must notify the physician immediately. Review of Policy and Procedure for [CONDITION(S)]/[CONDITION(S)], undated, stated in part the doctor must be notified for blood sugars less than 60 of greater than 400. If [CONDITION(S)] or [CONDITION(S)] does not resolve, notify the doctor and send to the hospital. It was determined these failures placed residents in an Immediate Jeopardy (IJ) situation from [DATE] to [DATE]. Although Resident #1 expired on [DATE], the facility did not have trainings for the staff until [DATE] and the QAPI did not met until [DATE]. On [DATE] at 4:09 PM the DON was informed that there was an immediate jeopardy. The facility took the following action to correct the non-compliance on [DATE]: 1) In-service regarding notification of change in condition policy - [DATE], [DATE] a. Notify MD/family for significant changes: incidents, weight loss, medical changes. b. Life-threatening emergencies: fractures, [CONDITION(S)], [CONDITION(S)] c. Extreme emergencies: must notify MD immediately, call 911 and transfer to hospital if MD does not respond d. [CONDITION(S)]: signs and symptoms: cold, clammy, restlessness e. HS snacks for patients on insulin f. [CONDITION(S)] interventions: juice, mild, sugar, [MEDICATION(S)] 2. In-service on Advance Directive on [DATE] and [DATE] a. DNR b. Comfort Care c. Palliative Care d. Hospice e. Patients on DNR can still be sent to the hospital if deteriorating. Notify MD and family about decision. 3. QAPI reviewed the concerns on [DATE] a. Notification of significant changes for MD and family b. Must not borrow meds c. Must notify MD for BS below 60. Administer [MEDICATION(S)] as ordered d. Hypoglycemic measures: sugar, juice, milk, [MEDICATION(S)] order. e. If non-responsive to measures within 30 minutes must notify MD f. Send patient to hospital, if not responsive to above measures and notify MD 3. Counseling on LVN A on [DATE] 4. Counseling on LVN B on [DATE] 5. (Facility) Monitoring of Insulin Dependent Patients: 8 patients a. Monitoring: must monitor BS QD, AC & HS, or as ordered Send BS log to MD weekly and prn HgbA1C q 6 months and prn b. Notification: Any BS<60, insulin has to be held and notify MD immediately Notify MD, family, DON, Supervisor of any significant changes c. Hypoglycemic measures: cold, clammy, LOC, dizziness, AMS, etc. *juice, sugar, milk *glucose tablets, [MEDICATION(S)] as ordered *monitor response within 30 minutes. If not responsive, call MD again, if deteriorates send to hospital and notify MD and family d. Standing order: Obtain standing for [MEDICATION(S)] on insulin-dependent residents on admission e. Supplies: *stock e-kit with 2 does of [MEDICATION(S)] and replace ASAP if used. Call pharmacy provider for immediate replacement. Send for replacement daily. *Managed Care Provider has given facility with 2 doses of [MEDICATION(S)] and standing orders to give to hypoglycemic residents as needed. (Already in stock) f. Communication: Must endorse to oncoming shift about patients on hypoglycemic episodes and notification of family, MD and DON. 6. QI meeting with managed care provider [DATE] a. Notification of MD of significant changes b. Standing order ort [MEDICATION(S)] on hypoglycemic residents c. Standing order to send patients out in extreme emergencies without doctor's orders. Notify thereafter d. Provided stock of 2 doses of [MEDICATION(S)] Record review of the medical records on [DATE] of the remaining insulin dependent diabetics revealed there were no hypoglycemic episodes. Observation on [DATE] at 6:35 PM, with the DON and LVN B, revealed facility e-kit had 2 [MEDICATION(S)] kits. There were also 2 residents that had their own [MEDICATION(S)] kits in the med cart.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, psychological well-being in accordance with the comprehensive assessment and plan of care for one (ID #1) of three sampled residents reviewed for changes in condition. Licensed Vocational Nurse (LVN) A failed to conduct thorough assessment and report to the physician when (Certified Nurse Aide) CNA C reported 10/25/16 on the evening shift that resident #1 was complaining of pain to the right leg and was not able to stand and bear weight. LVN B failed to conduct a thorough assessment report to the physician when CNA D reported during the beginning of the night shift on 10/25/16 that resident #1 was having a lot of pain to the right hip when the resident was moved to provide incontinent care. On 10/26/16 Resident #1 was diagnosed with [REDACTED]. This failure resulted in delayed medical treatment for [REDACTED]. The finding included: Review of a Face Sheet dated 10/09/16 revealed Resident #1 was admitted on [DATE]. Review of the Physician ' s Progress Note dated 10/12/16 documented resident #1 was an [AGE] year old female with a [DIAGNOSES REDACTED]. Resident showed significant rigidity consistent with extrapyramidal symptoms. The resident stated she was sleeping well and eating well. No joint pain. Review of Quarterly Minimum Data Sets ((MDS) dated [DATE] for resident #1, documented in part: the Brief Interview for Mental Status (BIMS) to assess cognitive status was not conducted because the resident had Short-term and Long-term memory problems. Resident is only oriented to self and cognitive skills for Daily Decision Making are moderately impaired. Resident #3 had no Behavioral Symptoms, no pain, no contractures; mobility devices walker and wheelchair; frequently incontinent of bowel & bladder; no history of falls in the past 6 months. Review of the Nursing Restorative Care Program Notes dated October 2016 for resident #1 documented in part: Ambulate resident using a Front Wheel Walker with moderate assistance once a day. Review of the Incident Report dated 10/26/16 at 6:30 AM, for resident #1 documented in part: Resident complaining of pain to right leg. Swelling to right leg and inability to check range of motion due to pain. Description of Injury: Angulated [MEDICAL CONDITION] femoral neck. Review of the Hospital emergency room (ER) Report dated 10/26/17 at 1:54 PM, revealed resident #1 arrived to the ER by ambulance with Right hip pain, decreased Range of Motion (ROM) restricted by pain, right leg shorten with external rotation deformity, no bruising to right hip. Emergency Department (ED) Triage Assessment Pain Score: 10 (Pain rating scale from 0-10, 10 being the Worst Possible Pain). The exacerbating factor is movement. Wheelchair bound prior to her admission with some ability to walk very short distances with support. Oriented to person. Review of the Hospital x-ray report dated 10/26/16 at 3:38 PM, documented resident #1 had evidence of right femoral neck fracture noted. Osteopenia, and [MEDICAL CONDITION] changes. Review of the Hospital Discharge Summary dated 10/31/16 documented Discharge [DIAGNOSES REDACTED]. Review of the Provider Investigation Report dated 10/27/16 documented resident #1 had a fracture to the right femoral head. Origin of injury unknown. Resident complaining of pain to right leg. Swelling to right hip and pain with movement. Unable to do ROM to right hip. In a telephone interview on 11/15/16 at 3:04 PM, resident ' s daughter reported that she always comes every afternoon to feed her mother. On 10/25/16 my mother was sitting in her wheelchair and was complaining of pain to the right leg with movement. I attempted to lift her right leg and she complained of pain with minimal movement. My mother kept saying Ay, Ay my leg hurts. I immediately put her leg down and called LVN A to come and check my mother. I called back at night to check on my mother and LVN A told me that they had applied an [MEDICATION NAME] cream and that she was asleep. I called in the morning and talked to LVN G and he told me that they were not going to get my mother out of bed because she was complaining of pain to the right leg and he was going to call the doctor to get an order for [REDACTED]. The Orthopedic doctor told me the head of the right femur was cracked and had to be replaced. The daughter reported that prior to this incident her mother did not complain of pain. My mom is confused but is able to talk and tell you what she wants. In an interview on 11/14/16 at 11:10 AM, LVN A On 10/25/16 at 5:30 PM to 6:00 PM, I was in the dining room when the daughter of resident #1 asked to check her mother because she was complaining of pain to the lower extremities. Resident #1 is confused and kept pointing down to her legs when I slightly lifted the lower extremities and she complained of pain. I asked the Medication Aide (MA) E to give the resident Tylenol for pain and asked CNA C to take the resident to the room so I could check her. When I went to the resident ' s room, CNA C reported that she had called CNA E to help her transfer the resident #1 from the toilet to the wheelchair because she had noted that the resident could not stand up and bear weight on the right leg as usual and complained of pain with movement. I than assisted CNA C to lift the resident from the wheelchair to put her in bed because she could not stand and bear weight on the right lower extremity and complained of pain with movement and kept saying Ay, Ay. LVN A demonstrated to the surveyor how she had checked the range of motion to the lower extremities by moving the ankles and knees up and down while the resident was sitting in the wheelchair in the dining room. When the resident was lying in bed, I touched the right thigh the resident complained of pain and said AY, AY, it hurts, so I stopped. I did not check the right hip. I did not see any bruising, or swelling to the right thigh. I know now that I should have checked the whole leg including the right hip but I didn ' t ' t. After this incident, we were trained on how to check the ROM to the lower extremities, and the importance of checking the whole leg from the ankle to the hip joint for injury. We were also trained to immediately call the physician when a resident has a change in condition. LVN A confirmed that she had instructed CNA C to apply an [MEDICATION NAME] ointment to the resident ' s right knee to relieve the pain without a physician's order [REDACTED].#1 Tylenol for pain. Later in the shift, I don ' t recall what time, I went to check the resident and she was asleep. I did not report to the attending physician that resident #1 was having pain to the right leg with movement on 10/25/16. In an interview on 11/15/16 at 3:46 PM, MA E reported that on 10/25/16 at approximately 5:30 PM to 6:00 PM, resident #1 was sitting in her wheelchair in the dining room and noted that the daughter was slightly lifting the resident ' s right leg. The resident was holding on to her right knee and grimace when the leg was moved and kept saying Ay, Ay. I saw LVN A checked resident #1 in the dining room and asked me to give Tylenol for pain. In an interview on 11/14/16 at 4:21 PM, CNA C reported On 10/25/16 at approximately 4:30 PM, I got the resident #1 out of bed to sit her in the wheelchair to take her to the dining room for supper. I noted that the resident kept saying No, No but did not complain of pain. After supper I took resident #1 to the bathroom and at that time noted that the resident could not stand and put weight on her right leg. I called CNA E to come and help me transfer the resident because the resident would complain of pain to the right leg with movement and could not stand up. This was unusual because resident #1 could always stand up, and hold on the grab bars so I could clean her and dress her. I went to get LVN A so she could come to check the resident before we moved her again. CNA E and I lifted the resident from the toilet and sat her in the wheelchair and she complained of pain with movement. LVN A and I lifted the resident from the wheelchair to the bed and the resident continued to complain of pain to the right leg with movement. Resident #1 complained of pain when the nurse touched the right leg. The resident did not have any swelling or bruises on the right leg. LVN A gave me an [MEDICATION NAME] cream to apply to the resident ' s right knee. CNA C reported they have been trained to immediately report to the nurse if the resident complains of pain. In an interview on 11/15/16 at 2:31 PM, CNA E reported that on 10/25/16 CNA C had asked her to help her transfer resident #1 from the toilet to the wheelchair because the resident #1 could not stand, bear weight on the right leg and complained of pain to the right leg with movement. LVN A came in when we were transferring the resident to the wheelchair. LVN A helped CNA C put the resident in bed. CNA E reported that they have been trained to immediately report to the nurse if the resident complains of pain. If the resident complains of pain when care is provided, we stop and go get the nurse. In an interview on 11/14/16 at 3:14 PM, LVN B reported that she had worked on the night shift on 10/25/16. LVN B stated, At approximately 12 MN to 1:00 AM, CNA D came to the Nurses Station to report that the resident #1 was complaining of pain to the right leg with movement. I went to the room and noted that the resident was asleep, so I gently touched the right knee and the resident said Ay, Ay. I did not check the ROM to the right lower leg because I did not want to bother her because she was asleep. CNA D reported to me throughout the shift that resident #1 continued to complain of pain to the right leg with movement when incontinent care was provided every two hours, so at 4:20 AM, I gave resident #1 500 mg of Tylenol at 4:20 AM. I later checked went to check her and resident #1 told me that the Tylenol was effective, however when I gently touched the right leg she would grimace, and complained of pain to the right knee. The pain level at that time was at 6. I did not report to the attending physician that resident #1 was having pain to the right leg with movement on 10/25/16. After this incident, we were trained on how to check the ROM to the lower extremities, and the importance of checking the whole leg from the ankle to the hip joint for injury. We were also trained to immediately call the physician when a resident has a significant change in condition. Telephone interview on 11/16/16 at 10:32 AM, CNA D reported that she had worked on the night shift on 10/25/16. At the change of shift the 2-10 CNAs told me that resident #1 was having a lot of pain to the right leg with movement. At approximately 11:00 PM-12 Midnight I entered resident #1 ' s room and noted that it smelled like those ointments that are used for pain. I went to ask LVN B if resident #1 was having pain because she did not report to me at the start of shift if the resident was having pain. LVN B told me that resident #1 was having pain to the right knee. I noted that resident #1 was not herself on that day, she was not talking to me as usual when care was provided. Resident #1 usually sleeps most of the night and snores loudly, but on that night she was awake most of the night, lying in bed with her eyes opened. Resident #1 complained of pain all night and she would doze off but was not sleeping comfortable. She would grimace and had a lot of pain to the right leg with movement. I carefully moved her every two hours to provide incontinent care. I did not see any swelling or bruising to the right hip. I reported to LVN B several times on that day that resident #1 continued to complain of pain each time that I went in to provide incontinent care. I told CNA F on the morning shift not to get resident #1 up for a shower and to talk to LVN G to see if resident #1 could get out of bed because she had pain all night to the right leg. In an interview on 11/14/16 at 2:09 PM, CNA F reported On 10/26/16 at 6:00 AM, I was going to get resident #1 ready for her shower when the LVN B told me that resident #1 was complaining of pain to the right leg and to go and talk to the day nurse before I got the resident out of bed. I noted right away that she was not her usual self because she is always asleep at the beginning of the shift, but on that day she was awake, and was just lying in bed with her eyes opened and did not talk to me. After report LVN G LVN G told me to leave the resident #1 in bed so he could assess the resident. I did not move the resident on that day. In an interview on 11/15/16 at 10:27 AM, LVN G reported that he had worked the morning shift on 10/26/16. LVN B reported during report that resident #1 had been complaining of pain to the right leg with movement. I instructed CNA E to leave resident #1 in bed so I could go and asses the resident after report. When I checked resident #1 she was complaining of pain with movement to the right leg so I could not check the hip due to the pain level being at a 7-8. I told MA E give the resident #1 [MEDICATION NAME] for pain and went to call the physician to request an order for [REDACTED].#1 was able to stand and bear weight. LVN G reported that they have been trained to immediately report significant changes of condition to the physician. Review of the physician's order [REDACTED].#1 documented in part: [MEDICATION NAME] 600 mg by mouth every 8 hours as needed for pain; Tylenol 500 mg by mouth bid (twice a day) as needed for pain. Pain assessment once a shift. Review of the Medication Administration Record [REDACTED] 1) 10/25/16 at 5:56 PM, MA E administered Tylenol 500 mg by mouth for pain level of 8 to the right knee. Follow-up Pain: by LVN A documented pain level-0; 2) 10/26/16 at 4:20 AM, LVN B administered Tylenol 500 mg by mouth for pain level of 6 to the right knee. Follow-up Pain: by LVN B documented pain level-0; 3) 10/26/16 at 7:11 AM, MA E administered Tylenol 500 mg by mouth for pain level of 7 Right leg pain. Follow-up Pain at 7:38 PM: by LVN G documented pain level-5; 4) 10/26/16 at 10:52 AM, MA E administered [MEDICATION NAME] 600 mg by mouth for pain level of 10 hip pain. Follow-up Pain at 7:38 PM: by LVN G documented pain level-5. Review of the Nurses Notes for resident #1 documented in part: Revealed there was no documentation in the Nurses Notes for 10/25/16; Nurses Note dated 10/26/16 written by LVN G documented-Received report resident complaining of pain to lower extremities. Resident was assessed at 6:30 AM, verbal complain of pain to Right Hip area with mild swelling. Unable to check (ROM) Right leg due to pain. Call placed to mobile x-ray company for x-ray of the right hip. Resident to remain in bed until x-ray results. X-ray done at 9:40 AM. Received x-ray results at 11:00 AM, results Angulated [MEDICAL CONDITION] Femoral Neck. Call placed to physician, pending return call. Resident in bed, medicated for pain. Attending physician returned telephone call at 11:20 AM, and gave orders to send resident #1 to ER (emergency room ) for evaluation and treatment. Call placed to responsible party at 11:30 AM, and informed of resident ' s condition and order to transfer resident to the hospital. In an interview on 11/15/16 Admission Coordinator Registered Nurse (RN) H stated Our facility policy is that nurses will immediately notify the attending physician for a significant change in condition. I have trained the nurses to assess ROM to the upper and lower extremities. If there is limitation of movement, pain, swelling, the physician must be notified immediately. Review of the facility ' s undated policy on Pain provided by RN H on 11/15/16 documented in part: Pain evaluation as needed. Notify Physician for treatment and medications. The census sheet dated 11/14/16 documented 19 residents in the West Wing.

Based on interview and record review the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status condition with a need for medical/physician intervention for 1 (resident # 1) of 3 residents reviewed for notification of changes in condition. Licensed Vocational Nurse (LVN) A failed to immediately report to the physician when (Certified Nurse Aide) CNA C reported 10/25/16 on the evening shift that resident #1 was complaining of pain to the right leg and was not able to stand and bear weight. LVN B failed to immediately report to the physician when CNA D reported during the beginning of the night shift on 10/25/16 that resident #1 was having pain to the right hip when the resident was moved to provide incontinent care. On 10/26/16 resident #1 was diagnosed with [REDACTED]. This failure resulted in delayed medical treatment for [REDACTED]. The finding included: Review of a Face Sheet dated 10/09/16 revealed Resident #1 was admitted on [DATE]. Review of the Physician ' s Progress Note dated 10/12/16 documented resident #1 was an [AGE] year old female with a [DIAGNOSES REDACTED]. Resident showed significant rigidity consistent with extrapyramidal symptoms. The resident stated she was sleeping well and eating well. No joint pain. Review of Quarterly Minimum Data Sets ((MDS) dated [DATE] for resident #1, documented in part: the Brief Interview for Mental Status (BIMS) to assess cognitive status was not conducted because the resident had Short-term and Long-term memory problems. Resident is only oriented to self and cognitive skills for Daily Decision Making are moderately impaired. Resident #3 had no Behavioral Symptoms, no pain, no contractures; mobility devices walker and wheelchair; frequently incontinent of bowel & bladder; no history of falls in the past 6 months. Review of the Nursing Restorative Care Program Notes dated October 2016 for resident #1 documented in part: Ambulate resident using a Front Wheel Walker with moderate assistance once a day. Review of the Incident Report dated 10/26/16 at 6:30 AM, for resident #1 documented in part: Resident complaining of pain to right leg. Swelling to right leg and inability to check range of motion due to pain. Description of Injury: Angulated [MEDICAL CONDITION] femoral neck. Review of the Hospital emergency room (ER) Report dated 10/26/17 at 1:54 PM, revealed resident #1 arrived to the ER by ambulance with Right hip pain, decreased Range of Motion (ROM) restricted by pain, right leg shorten with external rotation deformity, no bruising to right hip. Emergency Department (ED) Triage Assessment Pain Score: 10 (Pain rating scale from 0-10, 10 being the Worst Possible Pain). The exacerbating factor is movement. Wheelchair bound prior to her admission with some ability to walk very short distances with support. Oriented to person. Review of the Hospital x-ray report dated 10/26/16 at 3:38 PM, documented resident #1 had evidence of right femoral neck fracture noted. Osteopenia, and [MEDICAL CONDITION] changes. Review of the Hospital Discharge Summary dated 10/31/16 documented Discharge [DIAGNOSES REDACTED]. Review of the Provider Investigation Report dated 10/27/16 documented resident #1 had a fracture to the right femoral head. Origin of injury unknown. Resident complaining of pain to right leg. Swelling to right hip and pain with movement. Unable to do ROM to right hip. In a telephone interview on 11/15/16 at 3:04 PM, resident ' s daughter reported that she always comes every afternoon to feed her mother. On 10/25/16 my mother was sitting in her wheelchair and was complaining of pain to the right leg with movement. I attempted to lift her right leg and she complained of pain with minimal movement. My mother kept saying Ay, Ay my leg hurts. I immediately put her leg down and called LVN A to come and check my mother. I called back at night to check on my mother and LVN A told me that they had applied an [MEDICATION NAME] cream and that she was asleep. I called in the morning and talked to LVN G and he told me that they were not going to get my mother out of bed because she was complaining of pain to the right leg and he was going to call the doctor to get an order for [REDACTED]. The Orthopedic doctor told me the head of the right femur was cracked and had to be replaced. The daughter reported that prior to this incident her mother did not complain of pain. My mom is confused but is able to talk and tell you what she wants. In an interview on 11/14/16 at 11:10 AM, LVN A On 10/25/16 at 5:30 PM to 6:00 PM, I was in the dining room when the daughter of resident #1 asked to check her mother because she was complaining of pain to the lower extremities. Resident #1 is confused and kept pointing down to her legs when I slightly lifted the lower extremities and she complained of pain. I asked the Medication Aide (MA) E to give the resident Tylenol for pain and asked CNA C to take the resident to the room so I could check her. When I went to the resident ' s room, CNA C reported that she had called CNA E to help her transfer the resident #1 from the toilet to the wheelchair because she had noted that the resident could not stand up and bear weight on the right leg as usual and complained of pain with movement. I than assisted CNA C to lift the resident from the wheelchair to put her in bed because she could not stand and bear weight on the right lower extremity and complained of pain with movement and kept saying Ay, Ay. LVN A demonstrated to the surveyor how she had checked the range of motion to the lower extremities by moving the ankles and knees up and down while the resident was sitting in the wheelchair in the dining room. When the resident was lying in bed, I touched the right thigh the resident complained of pain and said AY, AY, it hurts, so I stopped. I did not check the right hip. I did not see any bruising, or swelling to the right thigh. I know now that I should have checked the whole leg including the right hip but I didn ' t ' t. After this incident, we were trained on how to check the ROM to the lower extremities, and the importance of checking the whole leg from the ankle to the hip joint for injury. We were also trained to immediately call the physician when a resident has a change in condition. LVN A confirmed that she had instructed CNA C to apply an [MEDICATION NAME] ointment to the resident ' s right knee to relieve the pain without a physician's order [REDACTED].#1 Tylenol for pain. Later in the shift, I don ' t recall what time, I went to check the resident and she was asleep. I did not report to the attending physician that resident #1 was having pain to the right leg with movement on 10/25/16. In an interview on 11/15/16 at 3:46 PM, MA E reported that on 10/25/16 at approximately 5:30 PM to 6:00 PM, resident #1 was sitting in her wheelchair in the dining room and noted that the daughter was slightly lifting the resident ' s right leg. The resident was holding on to her right knee and grimace when the leg was moved and kept saying Ay, Ay. I saw LVN A checked resident #1 in the dining room and asked me to give Tylenol for pain. In an interview on 11/14/16 at 4:21 PM, CNA C reported On 10/25/16 at approximately 4:30 PM, I got the resident #1 out of bed to sit her in the wheelchair to take her to the dining room for supper. I noted that the resident kept saying No, No but did not complain of pain. After supper I took resident #1 to the bathroom and at that time noted that the resident could not stand and put weight on her right leg. I called CNA E to come and help me transfer the resident because the resident would complain of pain to the right leg with movement and could not stand up. This was unusual because resident #1 could always stand up, and hold on the grab bars so I could clean her and dress her. I went to get LVN A so she could come to check the resident before we moved her again. CNA E and I lifted the resident from the toilet and sat her in the wheelchair and she complained of pain with movement. LVN A and I lifted the resident from the wheelchair to the bed and the resident continued to complain of pain to the right leg with movement. Resident #1 complained of pain when the nurse touched the right leg. The resident did not have any swelling or bruises on the right leg. LVN A gave me an [MEDICATION NAME] cream to apply to the resident ' s right knee. CNA C reported they have been trained to immediately report to the nurse if the resident complains of pain. In an interview on 11/15/16 at 2:31 PM, CNA E reported that on 10/25/16 CNA C had asked her to help her transfer resident #1 from the toilet to the wheelchair because the resident #1 could not stand, bear weight on the right leg and complained of pain to the right leg with movement. LVN A came in when we were transferring the resident to the wheelchair. LVN A helped CNA C put the resident in bed. CNA E reported that they have been trained to immediately report to the nurse if the resident complains of pain. If the resident complains of pain when care is provided, we stop and go get the nurse. In an interview on 11/14/16 at 3:14 PM, LVN B reported that she had worked on the night shift on 10/25/16. LVN B stated, At approximately 12 MN to 1:00 AM, CNA D came to the Nurses Station to report that the resident #1 was complaining of pain to the right leg with movement. I went to the room and noted that the resident was asleep, so I gently touched the right knee and the resident said Ay, Ay. I did not check the ROM to the right lower leg because I did not want to bother her because she was asleep. CNA D reported to me throughout the shift that resident #1 continued to complain of pain to the right leg with movement when incontinent care was provided every two hours, so at 4:20 AM, I gave resident #1 500 mg of Tylenol at 4:20 AM. I later checked went to check her and resident #1 told me that the Tylenol was effective, however when I gently touched the right leg she would grimace, and complained of pain to the right knee. The pain level at that time was at 6. I did not report to the attending physician that resident #1 was having pain to the right leg with movement on 10/25/16. After this incident, we were trained on how to check the ROM to the lower extremities, and the importance of checking the whole leg from the ankle to the hip joint for injury. We were also trained to immediately call the physician when a resident has a significant change in condition. Telephone interview on 11/16/16 at 10:32 AM, CNA D reported that she had worked on the night shift on 10/25/16. At the change of shift the 2-10 CNAs told me that resident #1 was having a lot of pain to the right leg with movement. At approximately 11:00 PM-12 Midnight I entered resident #1 ' s room and noted that it smelled like those ointments that are used for pain. I went to ask LVN B if resident #1 was having pain because she did not report to me at the start of shift if the resident was having pain. LVN B told me that resident #1 was having pain to the right knee. I noted that resident #1 was not herself on that day, she was not talking to me as usual when care was provided. Resident #1 usually sleeps most of the night and snores loudly, but on that night she was awake most of the night, lying in bed with her eyes opened. Resident #1 complained of pain all night and she would doze off but was not sleeping comfortable. She would grimace and had a lot of pain to the right leg with movement. I carefully moved her every two hours to provide incontinent care. I did not see any swelling or bruising to the right hip. I reported to LVN B several times on that day that resident #1 continued to complain of pain each time that I went in to provide incontinent care. I told CNA F on the morning shift not to get resident #1 up for a shower and to talk to LVN G to see if resident #1 could get out of bed because she had pain all night to the right leg. In an interview on 11/14/16 at 2:09 PM, CNA F reported On 10/26/16 at 6:00 AM, I was going to get resident #1 ready for her shower when the LVN B told me that resident #1 was complaining of pain to the right leg and to go and talk to the day nurse before I got the resident out of bed. I noted right away that she was not her usual self because she is always asleep at the beginning of the shift, but on that day she was awake, and was just lying in bed with her eyes opened and did not talk to me. After report LVN G LVN G told me to leave the resident #1 in bed so he could assess the resident. I did not move the resident on that day. In an interview on 11/15/16 at 10:27 AM, LVN G reported that he had worked the morning shift on 10/26/16. LVN B reported during report that resident #1 had been complaining of pain to the right leg with movement. I instructed CNA E to leave resident #1 in bed so I could go and asses the resident after report. When I checked resident #1 she was complaining of pain with movement to the right leg so I could not check the hip due to the pain level being at a 7-8. I told MA E give the resident #1 [MEDICATION NAME] for pain and went to call the physician to request an order for [REDACTED]. The x-ray was done at 9:40 AM and received x-ray results at 11:00 AM that documented resident #1 had an Angulated [MEDICAL CONDITION] Femoral Neck. Telephone call placed to the physician, and he called back at 11:20 AM, and gave orders to send resident #1 to ER (emergency room ) for evaluation and treatment. LVN G reported that prior to this incident, resident #1 was able to stand and bear weight. LVN G reported that they have been trained to immediately report significant changes of condition to the physician. In an interview on 11/15/16 Registered Nurse (RN) Admission Coordinator stated Our facility policy is that nurses will immediately notify the attending physician for a significant change in condition. I have trained the nurses to assess ROM to the upper and lower extremities. If there is limitation of movement, pain, swelling, the physician must be notified immediately. The census sheet dated 11/14/16 documented 19 residents were in the West Wing.

Based on observation, interview and record review, the facility failed to ensure each resident received supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #3) reviewed for supervision. The facility failed to provide supervision to prevent and elopement by Resident #3, who had been assessed to be at moderate risk for elopement. On the morning of 10/02/16 facility staff were aware a door lock was not functioning, but failed to take action to fix it. Resident #3 eloped from the facility through the door with the non-functioning lock on 10/02/16, and he was found by the facility staff in the alley behind the facility. An IJ was identified on 10/21/16. While the IJ was removed on 10/22/16 the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility ' s need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. This failure could affect 2 resident identified as being at moderate risk of elopement placed them in danger of leaving the facility unsupervised that could result in harm or death. Findings Include: Review of the undated face sheet revealed Resident #3 was a [AGE] year old male re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Wandering assessment dated [DATE] for resident #3 documented: Independently ambulatory, disoriented to place and time, with history of wandering. Total Risk points 11 (score of 11-20 indicates resident is at moderate risk for elopement and requires increased supervision). Review of the Fall Risk assessment dated [DATE] for resident #3 documented in part: Total Score 14, represents high risk for falls. Review of Quarterly Minimum Data Sets ((MDS) dated [DATE] and 10/14/16 for resident #3 documented in part: the Brief Interview for Mental Status (BIMS) to assess cognitive status was not conducted because the resident was rarely/never understood. Resident has Short-term and Long-term memory problems. Resident is only oriented to self and cognitive skills for Daily Decision Making are severely impaired. The MDS forms dated 07/14/16 and 10/14/16 documented resident #3 had no Behavioral Symptoms. Review of Care Plan for Resident #3 updated 06/26/16 prior to incident on 10/02/16 documented in part: Problem: Wandering Approaches: Wanders within safe boundaries. Monitor closely. Not exit seeking. Just wandering aimlessly. Care Plan for Wandering was updated 7/10/16 and documented Continue POC (Plan of Care). Review of Care Plan for Resident #3 updated 10/02/16 documented in part: Problem: Elopement/Wandering Goal- Resident will not wander out of facility within 90 days Approaches: · Monitor resident location every 1 hour Review of the Incident Report dated 10/02/16, documented resident #3 left the facility through the Laundry exit and was found in the alley behind the dumpster at 3:15 PM. The resident had no injuries. Review of Care Plan Note dated 10/10/16 documented in part: On Sunday 10/02/16, resident #3 could not be found inside facility, when searching noted the Laundry door was opened. Resident was found behind the trash bin. No injury noted. Continue to monitor resident every 2 hours and as needed. Maintenance replaced Key Pad on 10/02/16. Offer resident fluids and snacks. Keep resident busy with activities. In a telephone interview on 10/18/16 at 4:24 PM, with family member reported that resident #3 had eloped through the laundry room exit door that leads to the alley behind the facility on 10/02/16. He was found by the facility staff by the Garbage Can. I talked to the facility owner and he told me not to worry. I am very worried because anything can happen to resident #3 because he is very confused. Observation and interview on 10/19/16 at 2:23 PM, with Maintenance Worker and Administrator revealed there was an Electronic Keypad Lock on the door in the main dining room that opens to Laundry room. There was a small ramp that went up to the small area where the employee's dining area is located and to the left side was the small Laundry room. There was a wooden door and a screen door in the laundry room that opened to the alley behind the facility. It was observed that the asphalt was cracked, and there were missing pieces of asphalt directly in front of the exit door. The asphalt was uneven and there was a copious amount of small rocks (size of a dime/nickel) and large rocks (size of a tennis ball) in the alley. There were also multiple tire marks on the dirt in the alley. The Maintenance worker reported that cars pass very frequently in the alley. The distance measured by the Maintenance worker from the Laundry room exit to the Dumpster was 62 feet. The Dumpster was on an uneven surface and there were weeds and rocks around the sides of the Dumpster. Telephone interview on 10/20/16 at 3:45 PM with the Housekeeping Supervisor stated, I noted on 10/02/16 that the Electronic Keypad lock on the door in the main dining room that leads to the Laundry Room/Employee Dining area was opening without entering the access code at approximately 6:15 AM- 6:20 AM. I reported this to the Director of Nurses (DON) at 8:30 AM, on that day when I saw her taking resident to the main dining room for activities. I also reported this to the Maintenance Director at 9:00 AM and to the nurse that was working on the morning shift. I don't remember the name. The Housekeeping Supervisor reported that they had been trained to report to the Nurses or the Maintenance Director right away if the alarms on the exit doors were not working properly. In an interview on 10/20/16 at 2:22 PM, Certified Nurse Aide (CNA) D reported that on 10/02/16 at 2:10 PM, resident #3 was sitting in the main dining room and she gave him a snack before she went to shower another resident. It was about 3:00 PM, when I finished showering the other resident and I went to the dining room to check if resident #3 needed to be changed, because he is incontinent of bowel & bladder, but he was not there. That is when I noted that the door to the main dining room that leads to the Employee Lounge/Laundry Room was opened. I went up the small ramp and saw LVN E and told her that I was looking for resident #3. Both of us went to the Laundry Room and noted that doors were wide opened. We immediately went out to the alley to look for resident #3. We did not find him. I remember on the that day I noted at the beginning of the shift that Electronic Keypad Lock on the door in the main dining room would open without entering the access code. I immediately reported this to the Nurse on duty. The nurse told me that she and CNA B were aware that the Electronic Keypad Lock on the door was not working. CNA D reported that they had been trained to report to Nurses right away if the alarms on the exit doors were not working properly. Confidential interview on 10/19/16 at 9:28 AM, stated, On Sunday 10/02/16 at approximately 1:00 PM, I was about to enter the code in the Electronic Keypad Lock on the door in the main dining room when the Nurse that worked from 6:00 AM to 2:00 PM told me not to bother putting in the access code in the Keypad because the door lock was not locking. He said just push the handle down and the door will open. This exit door in the dining room is utilized continuously during the day by the facility staff. There is a door to the right that opens to the outside to an enclosed area used by maintenance staff to store equipment, and to the left is the laundry room where the exit door opens to the alley behind the facility. In an interview on 10/19/16 at 11:09 AM, Licensed Vocational Nurse (LVN) A reported that he had worked on 10/02/16 from 6:00 AM to 2:00 PM, and denied knowing that the Electronic Keypad Lock in the main dining room was not working properly on that day during his shift. LVN A stated Resident #3 walks independently all over the facility. A lot of the times he wanders into other resident rooms, but he had never attempted to elope before the incident. In an interview on 10/19/16 at 1:59 PM, the Maintenance Supervisor reported that he had received a telephone call from CNA B on 10/02/16 at approximately 4:15 PM. She said that the DON had told her to call me to report that the Electronic Keypad Lock in the main dining room was not locking. I went to pick up my assistant and came back to the facility at 4:30 PM. When we got there, I got a telephone call from the Administrator, he wanted to know if the facility staff had called me to report that the Electronic Keypad Lock in the main dining room was not working. The Administrator came in on that day to bring a new Electronic Keypad Lock and we installed the new lock on that day. The Maintenance Supervisor reported that the facility staff had been trained to immediately report to the Nurses, Maintenance workers and the Administrator if the door alarms/electronic locks are not working properly. In an interview on 10/19/16 at 3:00 PM, the Administrator reported that the DON had called him on 10/02/16 at approximately 3:00 PM, to report that the exit door in the main dining would open without inputting the access user code in the keypad. I came to the facility on that day at approximately 4:55 PM, to bring a new Key Pad Lock for the Maintenance workers to install. At that time the DON reported to me that resident #3 had left the facility through the exit door in the laundry room. She reported that she had found the doors in the laundry room wide opened and she had found the resident standing behind the dumpster in the alley at approximately 3:10 PM to 3:15 PM. The Administrator stated that the facility staff had been trained to immediately report to the Nurses, Maintenance workers and the Administrator if the door alarms/electronic locks are not working properly. In an interview on 10/19/16 at 2:49 PM, LVN C reported resident #3 was confused and oriented to person, and ambulates independently very slowly all over in the facility. I saw him sitting in the small dining room next to his room at approximately 2:40 PM. CNA D came to report to me at approximately 3:00 PM, that she could not find resident #3. She reported that she had last seen him sitting in the main dining room eating his snack. She stated that she had noted that the door in the main dining room that leads to the Laundry Room was opened and the exit doors in the Laundry room were wide opened. She reported that she and another employee went outside to look for resident #3 in the alley but did not find him. He was found at approximately 3:10 PM to 3:15 PM by the DON, standing behind the Dumpster. He had no apparent injuries. LVN C reported that resident #3 had never attempted to elope from the facility. No one reported to me on that day that the Electronic Keypad Lock in the main dining room was not locking. LVN C reported that the facility staff had been trained to immediately report to the Charge Nurse, Maintenance workers, Director of Nurses (DON) and the Administrator if the door alarms/electronic locks are not working properly. Telephone interview on 10/20/16 at 2:57 PM, DON stated I was in my office at approximately 3:00 PM, on 10/02/16 and someone came to tell me that they could not find resident #3. I immediately went to the main dining room and noted that the door in the main dining room opened without entering the access code to unlock the door. I went up to the laundry room and noted that the exit door was opened, so I went out to look for him in the alley. I found resident #3 in the alley standing behind the Dumpster. I brought him inside and he was assessed by the nurse. He had no injuries. The DON stated, I was very mad because no one reported to me on that day that the lock on the dining room door was not working properly. The DON stated that the facility staff had been trained to immediately report to the Nurses, Maintenance workers, DON and the Administrator if the door alarms/electronic keypad locks are not working properly. In an interview on 10/21/16 at 9:50 AM, CNA B reported that on 10/02/16 at approximately 2:00 PM to 3:00 PM, the DON reported to me that resident #3 was in the dining room pulling his pants down. I went to assist the resident and went back to the East side to finish with my documentation. Approximately 10-15 minutes later, CNA D came to tell me that she could not find resident #3. I immediately went to notify LVN C and also informed the West side CNAs. Everyone looked for him and we did not find him inside or outside of the facility. I took my truck and drove around the neighborhood for approximately 10-15 minutes and did not find him. As I was driving back to the facility, CNA D waved at me and I stopped and at that time she told me that they had already found resident #3. CNA B stated that the facility staff had been trained to immediately report to the Nurse if the door alarms/electronic keypad locks are not working properly. In an interview on 10/21/16 at 10:23 AM, LVN E stated, At approximately 3:00 PM, on the day of the incident, I was in the Employee Dining area by the Laundry Room when CNA D told me that she could not find resident #3. CNA D and I went to the Laundry Room and noted that the doors that opens to the alley were wide opened. We went outside to look for him in the alley and did not find the resident. I passed by the Dumpster in the alley that is close to the facility and did not see. Approximately 10-15 minutes later the DON reported that she had found resident #3 in the alley by the Dumpster. In an interview on 10/24/16 at 9:18 AM, Administrator reported that the Admission Coordinator had conducted the internal investigation and found that the Housekeeping Supervisor had noted that the Electronic Keypad Lock on the exit door in the main dining room was opening without entering the access code at approximately 6:30 AM. The investigation findings revealed that the DON and Maintenance Director had failed to immediately report to the Administrator that the Electronic Keypad Lock on the exit door in the main dining room was opening without entering the access code . The Administrator stated that the facility staff had been trained to immediately report to the Administrator, DON, Nurse, and Maintenance Director if the alarms/electronic locks were not working properly. Review of the receipt provided by Administrator on 10/19/16 at 11:00 AM documented in part: 10/02/16 at 4:47 PM, purchased a Commercial Electronic Keypad Entry Lock. An IJ was identified on 10/21/16 at 11:35 AM and the administrator was informed. The Plan of Removal was accepted on 10/21/16 at 4:24 PM and it included the following: Corrective Actions for Resident #3 Corrective Action to Reduce Risk of Exit Seeking Behavior 1. The Electronic Keypad Lock in the main dining room was replaced on 10/02/16 with a Commercial Electronic Keypad Lock. The Electronic Keypad Lock unlocks after a valid User Code is entered. Batteries will be replaced when the unit indicates the batteries are low. Batteries will be kept at the Nurses Station. 2. Bid Proposal was signed on 10/20/16, for installation of a Laser Lock for the exit door in the main dining room area. Pending delivery of lock. Vendor will provide tracking number for order. 3. Door Alarm with Keypad was installed on the Laundry Room exit door where resident #3 exited the building, installation was completed on 10/21/16 at 2:30 PM. The Door Alarm can only be deactivated by inputting a code. 4. Door Alarms with Keypads on the two exit doors at the end of the hallways on the West Side are appropriate because these doors open to a secure enclosed patio area. These doors are only used for emergency. 5. Laser Locks can only be opened by a Laser card. Laser Locks were installed on the exit doors by the Kitchen, Minimum Data Set (MDS) office, and the Front Gate. In the event of a fire these doors will automatically unlock. As a backup system there is a Push to Exit Button that when lifted will release the Laser Locks. 6. Quality Assurance (QA) checks and Monitoring was initiated on 10/21/16 to ensure alarms and doors are working properly: A. Maintenance will check exit doors and alarms on the 6-2 shift and document findings in QA Binder. If a problem is identified will immediately inform Administrator. A staff member will be assigned to supervise the exit until the door alarm is working properly. B. Charge Nurse will check exit doors and alarms every shift, and document findings in QA Binder. If a problem is identified will immediately inform Administrator and Maintenance. A staff member will be assigned to supervise the exit until the door alarm is working properly. C. DON will randomly check the 7 exit doors and document findings in QA Binder. If a problem is identified will immediately inform Administrator and Maintenance. A staff member will be assigned to supervise the exit until the door alarm is working properly. D. Administrator will randomly check alarms on a daily basis and review QA documentation to ensure compliance. Will document findings in QA Binder. If problem is found will develop a QA Action Plan to address areas of concern. 7. We currently identified two residents who are at risk of elopement. Resident #3 and Resident #4. 8. In-service training: i. Facility Staff were informed on 10/21/16 of residents identified at high risk for elopement. ii. Facility Staff will need to immediately report if Electronic Keypad Locks on doors and Door Alarms are not working properly to the following: 1. Charge Nurse 2. Director of Nurses 3. Administrator 4. Maintenance iii. The telephone numbers of the above facility staff are posted at the Nurses Station. iv. When the door alarms are not working properly a staff member designated by Administrative Staff will be assigned to supervise the exit to ensure that residents do not elope, until the door alarm is working properly. v. Facility staff that fails to immediately report will face appropriate disciplinary action. On 10/22/16 the surveyor confirmed by interviews with facility staff (4 LVNs, 7 CNAs, Receptionist, 1 Dietary Aide, 1 Medication Aide, 1 Laundry worker, Activity worker, 1 Housekeeper) and by record review and observations that facility staff were in-serviced on the above and were knowledgeable about changes in procedures. Observation on 10/22/16 at 6:04 AM, revealed that the Electronic Keypad Lock on the exit door in the main dining room was locked. Observation on 10/22/16 with the Administrator from 7:03 AM, revealed that the Electronic Keypad Lock on the exit door in the main dining room was locked. It was observed that the Laser locks on the Front Gate, exit door by the kitchen and exit door in the MDS office were working properly. It was observed that the alarms on the exit door on the West side were working properly. On 10/22/16 at 7:01 AM the Administrator was informed the Immediate Jeopardy was removed. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility ' s need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. In an interview on 10/21/16 at 11:35 AM, Administrator reported there were 2 residents identified at risk for elopement.

Based on observation, interview and record review, the facility failed to ensure each resident received supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for elopement. Resident #1 was assessed by the facility to be at high risk for elopement. Resident #1 eloped from the building on 07/02/16. Facility staff was not aware that she was missing until Resident #1's son called and informed them that she was at his sister ' s house (about 1 mile away). Resident #1 left facility and got a ride from a couple that she did not know and the couple gave Resident #1 a ride to her previous address where her daughter was currently staying. An IJ was identified on 08/25/16. While the IJ was removed on 08/26/16 the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility ' s need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. This failure could affect 1 resident identified as a wanderer at risk of leaving the facility unsupervised and place her in situations that could result in harm or death. Findings Include: Closed record review of the face sheet (undated) revealed Resident #1 was a [AGE] year old female admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) revealed the results of the Brief Interview for Mental Status (BIMS); A. Annual, 02/25/16 - BIMS as moderately impaired cognitive ability for daily decision making. B. Quarterly, 05/25/16 - BIMS as severely impaired cognitive ability for daily decision making. Review of Care Plan for Resident #1 dated 03/02/15 (updated on 05/30/16 and 07/03/16) revealed the following: Elopement/Wandering Update on 05/30/16 - Wandering assessment 05/21/16 = 26 high risk. Continue to monitor. Continue plan of care. Goal- Resident will not wander out of facility within 90 days Approach · Monitor resident location every 1 hour · Provide resident with 1:1 socialization to build trusting relationship with staff Review of Nurses ' notes dated 07/02/16 at 7:19 PM revealed that Resident #1 eloped from facility at 1:45 PM and was found a mile away from facility at 1:55 PM, her daughter ' s house. Resident #1 ' s daughter stated to staff that her mother was dropped off by a couple she did not recognize. Resident #1 was brought back by staff accompanied by Resident #1 son at 2:30 PM. At the time of arrival she was assessed, head to toe and no injuries noted. Review of Provider Investigation Report dated 07/02/16 at 3:30 PM revealed that Resident #1 left facility at approximately 1:45 PM (this time was not able to be confirmed). Resident was seen ambulating up and down hallways prior to elopement. Resident was found and returned to facility at 2:30 PM. A head to toe assessment was done and no injury was noted. In-service given on ways to redirect resident, prevent similar incident from happening again and 1:1 buddy assist. Doctor to reevaluate medication and referral for psych- evaluation on Resident #1. In a phone interview on 08/24/16 at 11:28 AM, Resident #1 son stated on July 2, 2016 his mother eloped from facility and arrived at his sister ' s house where Resident #1 previously lived. He stated the facility was not aware his mother (Resident #1) had left facility until he telephoned the facility with the information. He stated when he called the facility and asked to talk to his mother the facility staff stated they were looking for her and put him on hold. The staff returned to the phone and asked him what was going on and if he knew something. That is when he told them his sister had called him and told him his mother was at the house. He stated the staff stated they were sending a staff member to that location and would wait for his arrival. Once he got to his sister house the staff member asked him to return with them so she could be assessed by the nurse. When he arrived at the facility the nurse assessed her and no injuries were noted. He was told by facility staff that he needed to speak to Administration about the incident and to see what they can do to prevent other elopements. In an interview on 08/24/16 at 2:00 PM CNA A stated she was working on July 2, 2016 when Resident #1 eloped. She stated she had seen Resident #1 walking up and down the hall and asking for the phone to call her son at around 12:30 pm when she was at lunch. CNA A stated she was taking care of residents when she was made aware that Resident #1 could not be found and started looking for her within the facility. CNA A stated she did not know she had left the facility or which way. She stated she remember that Resident #1 had always mentioned to her that her house was close by and wanted to go. So she was asked to go in the car to look for her. She stated she looked for her at the bus stop and while out was called that she was at her old address. When she arrived Resident #1 was in the house and daughter was bringing her a glass of water. CNA A stated Resident #1 stated to her that she asked someone to give her a ride to her house. CNA A returned to facility with Resident #1 and her son where she was assessed by nurse. CNA A stated she was aware Resident #1 was an elopement risk and needed to monitor resident whereabouts every hour during the shifts. In an interview on 08/24/16 at 3:29 PM Activity Director stated Resident #1 would walk in the halls and would go outside in the patio area unsupervised. Resident #1 would ask for money to take the bus home. Activity Director stated the day of the elopement (7-2-16) the nurse asked her where Resident #1 was because her son was on the phone. Activity Director stated that staff were busy with patient care and did not know the location of the resident. The staff began to look for her and could not locate her. Activity Director spoke to Resident #1 ' s son on the phone and he stated Resident #1 was at his sister ' s house ( 1 mile away). Activity Director immediately made the nurse aware and the staff went to Resident #1 ' s address where she lived previously. Activity Director stated she was aware Resident #1 was an elopement risk and she always talked to her and redirected her with conversations. In a phone interview on 08/24/16 at 4:30 PM, Wheel chair washer B stated he was hired to wash the wheelchairs and was asked to monitor the elopement residents at the facility. He said he was hired to keep an eye on Resident #1 and would document on the elopement monitoring forms every hour for the residents. He stated Resident #1 would be waiting by the front gate (unsupervised) at times waiting for someone to leave and she would dart out. He stated he last saw the Resident #1 at 1:00 PM in the courtyard on July 2, 2016. He said Resident #1 was allowed to be in the courtyard unsupervised and he only had to document seeing her every hour. He stated he was not aware she had eloped from the facility on July 2, 2016. On 08/23/16, MapQuest was utilized to calculate the distance from the facility address to the address provided on the Provider Investigation Report where Resident #1 was located. The distance was 1.01 miles. Record review of facility monitoring elopement record dated May and June 2016 revealed monitoring for Resident #1 was done hourly by facility staff. Record review of facility monitoring elopement record dated July 3, 2016 revealed no initials on July 1st and 2nd, 2016 (Resident #1 Care Plan indicated she would be monitored every hour). Resident #2 eloped on July 2, 2016 (on the weekend). In an interview on 08/04/16 at 10:15 AM Nursing Home Administrator (NHA) stated Resident #1 eloped from the facility on July 2, 2016 which was a weekend. NHA stated they were not able to determine how or when Resident exactly left the facility. NHA stated the release button to get out of the gate was accessible to anyone and maybe a visitor or resident let her out. He also stated all residents are allowed to be in the courtyard unsupervised; even the ones that are known to be an elopement risk. Resident #1 was assessed by the nurse and had no injuries or dehydration. She was placed on 1:1 monitoring by a staff member, doctor was notified, DON, and himself. Observation on 08/24/16 at 4:40 PM two residents were in the courtyard unsupervised and staff were observed to push release button for front gate without checking to see who was coming in or out. Review of facility Elopement and Missing Resident Policy date 06/15/11 revealed the following: 1. Electronic Front Gate Lock: The front gate is equipped with an electronic lock and stays locked at all times. An employee or designated resident will unlock the gate if he or she will hear the buzz. An IJ was identified on 08/25/16 at 2:45 PM and the administrator was informed. The Plan of Removal was accepted on 08/26/16 at 5:25 PM and it included the following: Corrective Actions for Resident #1 Corrective Action to Reduce Risk of Exit Seeking Behavior 1. The facility removed the push button Switch (08/26/16) and the only way to access the gate is through the use of an access card and by pressing a 4 digit code. 2. Access cards are only given to authorized employees, such as secretary, Administration, Maintenance, and Nursing staff. 3. In-serviced staff on 07/10/16- Exit door by kitchen 4. Provided staff with key to enter through exit door by kitchen, when throwing trash. 5. In-serviced staff on 07/15/16- Elopement Policies and ADLs 6. Another activity personnel was hired and started activities on weekends starting 07/30/16. 7. Increased supervision of residents when in courtyard starting 08/25/16. A personnel must be with residents when in the courtyard until new system operational Sept. 09, 2016. 8. Push button has been removed and the only way visitors and staff are able to pass through gate is with a key card. 9. All residents who remain outside will supervised. 10. Staff in-service 08/26/16 about increase supervison of patients in the courtyard, closing the front door by 6:00 PM. New system will be installed within 2 -3 weeks. On 08/26/16 the surveyor confirmed by observations and interviews with nursing and administrative staff and by record review that nursing staff were in-serviced on the above and were knowledgeable about changes in procedures. A staff member was placed outside in the courtyard to supervise residents in the courtyard. On 08/26/16 at 5:25 PM the NHA was informed the IJ was removed. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility ' s need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. In an interview on 08/04/16 at 10:20 AM, NHA stated there was 1 resident identified at risk for elopement.

Based on observations, interviews and record review the facility failed to ensure 1 of 12 residents (Resident # 2) reviewed for elopement risk received adequate supervision to prevent elopement and accidents. Resident #2 had 2 attempts at elopement before he eloped on 6/27/14 at 5:00 AM. Resident #2 left from the alarming exit door at the end of the east hallway. This door exited onto a neighborhood street. The street surface was uneven with potholes, dips and alleyways. Resident #2 had an unsteady gait and traversed a street in the dark with few sidewalks and rocky, uneven ground. He was found by the police 10 blocks from the facility. An IJ was identified on 07/24/14. While the IJ was removed on 07/25/14 the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. This failure could affect 10 residents identified as wanderers at risk of leaving the facility without being seen by staff in situations that might lead to serious injury or death. Findings include: Review of the face sheet (undated) revealed Resident #2 was a [AGE] year-old man admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) revealed the results of the Brief Interview for Mental Status (BIMS); a. Admission, 2/24/14 - BIMS score of 1 (a score of 0-7 indicates severely impaired cognitive ability for daily decision-making) b. Quarterly, 4/10/14 - BIMS score of 5 A. First Wandering/Elopement Attempt: Record review of All Care Plans dated 4/20/14 LVN AA documented on 4/16/14 Resident #2 stood on a brick to attempt to jump over the fence. The resident stopped when he observed he was being watched. Review of Resident #2's Care Plan Order dated 4/20/14 documented the following: Problem: Elopement/Wandering Additional problems: Resident attempted to jump out of the fence Goal: Resident will not wander out of facility within 90 days. Approach: ? Provide resident with 1:1 socialization to build trusting relationship with staff ? Encourage group activities and attempt to keep resident occupied ? Wander guard and monitor effectiveness every week ? Assist resident in reorientation to room and facility with verbal cues ? Allow resident to assist AD (activity director) with daily activities, have him/her call out number during BINGO ? Put familiar items in resident room to assist resident to identify them ? Provide resident with reading material such as magazines as he verbalized enjoying them ? Discuss dangers of leaving facility without notifying staff: he can get lost, may be struck by a care while walking, he may be assaulted/robbed, he may become ill if he misses his medications In an interview on 7/23/14 at 2:30 PM, the Activity Director stated she played Bingo or Loteria once a week; however, she was not able to demonstrate that Resident #2 had been calling out the Bingo numbers, had participated in group activities or provided 1:1 socialization as stated in Resident #2's Care Plan for 4/20/14. She stated she did not document which residents participated in activities. Record review of Wandering assessment dated [DATE] after Resident #2's attempt to jump the fence on 4/20/14. The Wandering Assessment identified him at risk for wandering and recommended an increase in supervision. The Wandering Assessment identified Resident #2 was at risk for injury related to identified elopement risk factors and or exit-seeking behavior as evidenced by: showing signs/symptoms of depression/apathy, independently ambulatory, disoriented at times, impaired judgment, impulsivity, unable to follow instructions and current wandering. Wandering Assessment revealed Resident #2 scored total risk points of 14 which indicated he was a moderate risk, increase supervision and revealed he was a wandering risk. Record Review of the Nurses Notes from 4/1/2014-7/24/2014 revealed no additional supervision was provided by facility staff and no evidence the Care Plan had been updated. In an interview on 7/24/14 at 12 Noon, the Nursing Home Administrator (NHA) stated the facility did not have a wander guard system even though it had been Care Planned on 4/20/14. He stated the front gate and the exit doors had alarms. The NHA stated the employees were the only ones who would have the code to disarm the exit doors. B. Second Wandering/Elopement Attempt: Record review of Incident Report dated 6/14/14 revealed Resident #2 was found by CNA B lying on the ground in the maintenance shop area. He complained of pain to the hip areas and pain to the occipital part of the head and a small scrape on the lower forearm. Additional comments included the staff was to continue to monitor the resident and to keep the door leading to the laundry area tightly closed. Record Review of the Nurses Notes from 4/1/14 -7/24/14 revealed no Wandering or Elopement assessment was updated. There was no evidence of any Care Plan interventions implemented after this incident. In an interview on 7/22/14 at 8:30 AM, the Director of Nurses (DON) stated if a resident was at risk for elopement the facility policy was to begin the Elopement Record: 1 Hour Checks, which was the nurse on duty had to "Lay eyes on the resident every hour." The DON reviewed the Wandering assessment dated on 4/20/14 which revealed he was a wandering risk and required increased supervision. The DON stated Resident #2's supervision was not increased and the "Elopement Record: 1 Hour Checks" had not been implemented for the months of April 2014 or May 2014. She stated "we could not find any records for April or May; I don't know why we did not do it, if he was a wandering risk." The DON stated the Elopement Record 1 hour checks began on 6/27/14 the day Resident #2 eloped from the facility. Observation on 7/24/14 at 11:20 AM, the maintenance area was at the rear of the building. There was access from the laundry room through the alarmed door (which was open and not alarming) in the dining room. The door to the maintenance area was open wide and also the doorway to the alleyway. There was a steep 1 foot drop to step into the area. On the right there was a ladder with rope hanging about 5 feet off the ground. There were broken tiles on the floor, tools on the shelves, extension cords, staplers, crow bar, wrench, wire, an electric saw, hedge shears and an axe. There was a gallon gasoline container opened and filled with gasoline. Outside of the alleyway door is a lot of loose rocks on the ground. The door to the alleyway was made of wire fencing material. C. Successful Elopement Record review of the Incident Report dated 6/27/14 documented at 5:00 AM, Resident #2 eloped from the facility using the exit door adjacent to the kitchen (end of the east hallway). The door alarm sounded and the staff responded immediately, but the resident had exceeded visibility. Record review of the Provider Investigation Report dated 6/27/14 revealed Resident #2, who had a history of [REDACTED]. The staff immediately exited the same doorway to look for the resident but did not see him. The Investigation Summary was blank. The Provider Action Taken Post-Investigation included contacting a local Alzheimer's organization for an ID bracelet, continuous hourly monitoring and providing the Power of Attorney for Resident #2 with a 30 day discharge notice. Observation on 7/24/14 at 11:26 AM, revealed from the east hallway door from where Resident #2 eloped on 6/27/14, exited into the alleyway. Driving from the exit door to the street where the police stated Resident #2 was picked up was 0.6 miles or 10 blocks at the closest point to the facility. The street was uneven and had pot holes and missing pavement. There were some sidewalks along the way, but not continuous on any 1 side of the street. Where there were no sidewalks the ground was uneven and rocky. There were alleys on both sides of the street on each block. In an interview on 7/22/14 at 6:30 AM, Licensed Vocational Nurse (LVN) E stated, on the morning of 6/27/14, he observed Resident #2 walking around the building. LVN E stated, "I was sitting in the nurse's station. I heard the sound of the door alarm go on; I thought it was staff coming into work. The staff use the exit door located at the end of the east side resident hallway (same door Resident #2 utilized to elope) door frequently. They punch in the code and disable the alarm when they come in. The alarm kept sounding and I realized it was Resident #2 leaving." LVN E stated he did not respond to the door alarm immediately since the alarm sounds frequently because staff uses it to enter and exit the building. LVN E stated the resident was only gone for 20 minutes before he was returned by the police. LVN E stated he was not aware Resident #2 had any prior attempts to elope, wandering or falls. In an interview on 7/22/14 at 6:00 AM, Certified Nurse Aide (CNA) A stated she was working on the west side hallway on the day of the incident. CNA A stated she was assigned to care for Resident #2 on 6/27/14 (date of elopement). CNA A stated she was attending another resident when she heard the alarm ring on the east side after 5 AM. CNA A stated "LVN E said Resident #2 escaped. I don't know how he knew it was him but he knew it." CNA A stated she was instructed to look for Resident #2 in her car. "I drove around the area, it was dark, later the police found him; I can't remember the time he came back. All Resident #2 said is that he left to go get us hamburgers." CNA A stated the nurses had never notified her that Resident #2 was at risk for elopement. D. East Hallway In an observation on 7/22/14 at 6:00 AM, staff was seen entering the facility through the exit door located at the end of the east side resident hallway (same door Resident #2 utilized to elope). The door alarm rang each time the staff entered the facility. The staff would proceed to enter the door disabling code and alarm would stop ringing within a few seconds. In an observation on 7/23/14 at 9:35 AM, during rounds with the Maintenance Supervisor, the exit door located at the end of the east side resident hallway (same door Resident #2 utilized to elope) was opened by the milk delivery man who used a code to silence the alarm. The door was propped opened by the milk delivery man. There were no staff members observed to be monitoring the opened door. The Maintenance Supervisor stated, "It's opened because they are doing deliveries." Observation on 7/24/14 at 9:30 AM to 10:40 AM, the exit door located at the end of the east side resident hallway (door utilized by Resident #2 to elope) was opened and the alarm was triggered a total of 5 times. Three CNAs remained seated in the eastside dining room each time the alarm rang. The CNAs did not get up and verify the cause of the door alarm sound. Observation on 7/24/14 at 10:40 AM, LVN D sat in nurse's station on the east side hallway. The exit door at the east side resident hallway (door utilized by Resident #2 to elope) was opened by a staff member and the alarm rang for several seconds. LVN D did not get up from his seat to verify what had triggered the alarm. E. Other Alarmed Doors In an observation on 7/23/14 at 9:30 AM, the Laundry Attendant opened the door on the right side of the main dining room, propped it open with a door stopper, and set the door alarm to delay as she used this door to reach the laundry room. In an interview on 7/23/14 at 9:30 AM, the Laundry Attendant stated she was aware she should not leave the dining room door to the laundry room and maintenance shop opened or set the door alarm to delay. "The people can get out. There are two doors opened to the alley back there, I should not do that." In an interview on 7/23/14 at 11:50 AM, the DON said the door alarm should be on. She said, " The laundry and the CNAs should not put it (the alarm) on delay. " Observation on 7/24/14 at 1:04 PM, the door in the dining room to the laundry area was open and no alarm was sounding. The Comptroller closed the door and yelled to an unseen person to not leave the door open. In an interview on 7/24/14 at 12 Noon, the NHA stated staff could enter the facility using the front door and the exit door located at the end of the east side resident hallway (same door Resident #2 utilized to elope.) Review of Mountain Villa Nursing Center Elopement and Missing Resident Policy (6/15/11) revealed the admitting nurse will assess the resident if they have a tendency to wander out of the facility. Residents that have a history or tendency to wander outside will be monitored closely. Residents susceptible to elopement are ambulatory confused residents, alcoholic residents, generally young residents, sundowners, wheelchair bound that are capable to propel themselves. 2. Exit alarm: all major exit doors leading to the outside are equipped with alarm devices that will sound when the door is open. Alarms must be on at all times. The sound would not stop until it is reset with a password. An IJ was identified on 7/24/14; the Nursing Home Administrator was informed at 2:30 PM. Plan of Removal #4 was submitted by the facility and accepted on 7/25/14 at 6:06 PM.: A. In-service on elopement 4/20/14, 5/14/14,6/17/14,7/24/14,7/15/14-hourly monitoring, redirection activity reorient, reinforce, keep doors closed, answer alarms, call light, place in traffic areas, family visits. B. All wandering Care Plans updated on 7/25/14 C. Ten residents have been identified with wandering risk, interventions are: ? Hourly monitoring ? Elopement monitoring log ? High visibility areas ? Redirection -offer food, water ? Increase activities of their interest D. Residents will be identified by doing Wandering Assessment upon admission, upon change of condition, and every three months. E. Hourly checks for residents who around to be at moderate and high risk for wandering F. Upon first attempt to elopement facility will start discharge planning G. Staff in services on all departments on 7/24/14 and 7/25/14 and q weekly x4 weeks then monthly x4 reinforced then q 6 months to include: ? Employees use front gate as main entry ? Sign by front gate-elopement risk do not let residents go out ? Not using back door by kitchen as entry, use only for throwing trash and delivery ? Kitchen door alarm and door to laundry must be on at all times-do not disarm or delay ? during kitchen deliveries staff must supervise door to ensure that residents do not elope ? Vendors must ring bell for entry for deliveries ? Answer alarms as soon as possible ? keep all doors closed at all times ? Employees who find doors or alarms not working properly must notify maintenance promptly ? Employees must not disable alarm H. Maintenance will check all exits and alarms for proper closure daily I. Administrator has ensured compliance on 7/25/14 and will continue by periodic review, weekly x4, monthly x 4 and q 6 month ' s prn. On 7/25/14, through interviews with facility staff on the in-services provided and record reviews of current wandering assessments of residents identified at risk, the survey team determined that the interventions documented in the facility's action plan were implemented and the NHA was notified the immediate jeopardy was removed effective 7/25/14 at 6:06 PM. The facility remained out of compliance at a scope and severity of pattern of potential for more than minimal harm. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. In a list provided by the NHA on 7/25/14 at 5:30 PM, 10 residents were identified as wanderers.

Based on observations, interviews and record review the facility failed to ensure 1 of 12 residents (Resident # 2) reviewed for elopement risk received adequate supervision to prevent elopement and accidents. Resident #2 had 2 attempts at elopement before he eloped on 6/27/14 at 5:00 AM. Resident #2 left from the alarming exit door at the end of the east hallway. This door exited onto a neighborhood street. The street surface was uneven with potholes, dips and alleyways. Resident #2 had an unsteady gait and traversed a street in the dark with few sidewalks and rocky, uneven ground. He was found by the police 10 blocks from the facility. An IJ was identified on 07/24/14. While the IJ was removed on 07/25/14 the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. This failure could affect 10 residents identified as wanderers at risk of leaving the facility without being seen by staff in situations that might lead to serious injury or death. Findings include: Review of the face sheet (undated) revealed Resident #2 was a [AGE] year-old man admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) revealed the results of the Brief Interview for Mental Status (BIMS); a. Admission, 2/24/14 - BIMS score of 1 (a score of 0-7 indicates severely impaired cognitive ability for daily decision-making) b. Quarterly, 4/10/14 - BIMS score of 5 A. First Wandering/Elopement Attempt: Record review of All Care Plans dated 4/20/14 LVN AA documented on 4/16/14 Resident #2 stood on a brick to attempt to jump over the fence. The resident stopped when he observed he was being watched. Review of Resident #2's Care Plan Order dated 4/20/14 documented the following: Problem: Elopement/Wandering Additional problems: Resident attempted to jump out of the fence Goal: Resident will not wander out of facility within 90 days. Approach: ? Provide resident with 1:1 socialization to build trusting relationship with staff ? Encourage group activities and attempt to keep resident occupied ? Wander guard and monitor effectiveness every week ? Assist resident in reorientation to room and facility with verbal cues ? Allow resident to assist AD (activity director) with daily activities, have him/her call out number during BINGO ? Put familiar items in resident room to assist resident to identify them ? Provide resident with reading material such as magazines as he verbalized enjoying them ? Discuss dangers of leaving facility without notifying staff: he can get lost, may be struck by a care while walking, he may be assaulted/robbed, he may become ill if he misses his medications In an interview on 7/23/14 at 2:30 PM, the Activity Director stated she played Bingo or Loteria once a week; however, she was not able to demonstrate that Resident #2 had been calling out the Bingo numbers, had participated in group activities or provided 1:1 socialization as stated in Resident #2's Care Plan for 4/20/14. She stated she did not document which residents participated in activities. Record review of Wandering assessment dated [DATE] after Resident #2's attempt to jump the fence on 4/20/14. The Wandering Assessment identified him at risk for wandering and recommended an increase in supervision. The Wandering Assessment identified Resident #2 was at risk for injury related to identified elopement risk factors and or exit-seeking behavior as evidenced by: showing signs/symptoms of depression/apathy, independently ambulatory, disoriented at times, impaired judgment, impulsivity, unable to follow instructions and current wandering. Wandering Assessment revealed Resident #2 scored total risk points of 14 which indicated he was a moderate risk, increase supervision and revealed he was a wandering risk. Record Review of the Nurses Notes from 4/1/2014-7/24/2014 revealed no additional supervision was provided by facility staff and no evidence the Care Plan had been updated. In an interview on 7/24/14 at 12 Noon, the Nursing Home Administrator (NHA) stated the facility did not have a wander guard system even though it had been Care Planned on 4/20/14. He stated the front gate and the exit doors had alarms. The NHA stated the employees were the only ones who would have the code to disarm the exit doors. B. Second Wandering/Elopement Attempt: Record review of Incident Report dated 6/14/14 revealed Resident #2 was found by CNA B lying on the ground in the maintenance shop area. He complained of pain to the hip areas and pain to the occipital part of the head and a small scrape on the lower forearm. Additional comments included the staff was to continue to monitor the resident and to keep the door leading to the laundry area tightly closed. Record Review of the Nurses Notes from 4/1/14 -7/24/14 revealed no Wandering or Elopement assessment was updated. There was no evidence of any Care Plan interventions implemented after this incident. In an interview on 7/22/14 at 8:30 AM, the Director of Nurses (DON) stated if a resident was at risk for elopement the facility policy was to begin the Elopement Record: 1 Hour Checks, which was the nurse on duty had to "Lay eyes on the resident every hour." The DON reviewed the Wandering assessment dated on 4/20/14 which revealed he was a wandering risk and required increased supervision. The DON stated Resident #2's supervision was not increased and the "Elopement Record: 1 Hour Checks" had not been implemented for the months of April 2014 or May 2014. She stated "we could not find any records for April or May; I don't know why we did not do it, if he was a wandering risk." The DON stated the Elopement Record 1 hour checks began on 6/27/14 the day Resident #2 eloped from the facility. Observation on 7/24/14 at 11:20 AM, the maintenance area was at the rear of the building. There was access from the laundry room through the alarmed door (which was open and not alarming) in the dining room. The door to the maintenance area was open wide and also the doorway to the alleyway. There was a steep 1 foot drop to step into the area. On the right there was a ladder with rope hanging about 5 feet off the ground. There were broken tiles on the floor, tools on the shelves, extension cords, staplers, crow bar, wrench, wire, an electric saw, hedge shears and an axe. There was a gallon gasoline container opened and filled with gasoline. Outside of the alleyway door is a lot of loose rocks on the ground. The door to the alleyway was made of wire fencing material. C. Successful Elopement Record review of the Incident Report dated 6/27/14 documented at 5:00 AM, Resident #2 eloped from the facility using the exit door adjacent to the kitchen (end of the east hallway). The door alarm sounded and the staff responded immediately, but the resident had exceeded visibility. Record review of the Provider Investigation Report dated 6/27/14 revealed Resident #2, who had a history of [REDACTED]. The staff immediately exited the same doorway to look for the resident but did not see him. The Investigation Summary was blank. The Provider Action Taken Post-Investigation included contacting a local Alzheimer's organization for an ID bracelet, continuous hourly monitoring and providing the Power of Attorney for Resident #2 with a 30 day discharge notice. Observation on 7/24/14 at 11:26 AM, revealed from the east hallway door from where Resident #2 eloped on 6/27/14, exited into the alleyway. Driving from the exit door to the street where the police stated Resident #2 was picked up was 0.6 miles or 10 blocks at the closest point to the facility. The street was uneven and had pot holes and missing pavement. There were some sidewalks along the way, but not continuous on any 1 side of the street. Where there were no sidewalks the ground was uneven and rocky. There were alleys on both sides of the street on each block. In an interview on 7/22/14 at 6:30 AM, Licensed Vocational Nurse (LVN) E stated, on the morning of 6/27/14, he observed Resident #2 walking around the building. LVN E stated, "I was sitting in the nurse's station. I heard the sound of the door alarm go on; I thought it was staff coming into work. The staff use the exit door located at the end of the east side resident hallway (same door Resident #2 utilized to elope) door frequently. They punch in the code and disable the alarm when they come in. The alarm kept sounding and I realized it was Resident #2 leaving." LVN E stated he did not respond to the door alarm immediately since the alarm sounds frequently because staff uses it to enter and exit the building. LVN E stated the resident was only gone for 20 minutes before he was returned by the police. LVN E stated he was not aware Resident #2 had any prior attempts to elope, wandering or falls. In an interview on 7/22/14 at 6:00 AM, Certified Nurse Aide (CNA) A stated she was working on the west side hallway on the day of the incident. CNA A stated she was assigned to care for Resident #2 on 6/27/14 (date of elopement). CNA A stated she was attending another resident when she heard the alarm ring on the east side after 5 AM. CNA A stated "LVN E said Resident #2 escaped. I don't know how he knew it was him but he knew it." CNA A stated she was instructed to look for Resident #2 in her car. "I drove around the area, it was dark, later the police found him; I can't remember the time he came back. All Resident #2 said is that he left to go get us hamburgers." CNA A stated the nurses had never notified her that Resident #2 was at risk for elopement. D. East Hallway In an observation on 7/22/14 at 6:00 AM, staff was seen entering the facility through the exit door located at the end of the east side resident hallway (same door Resident #2 utilized to elope). The door alarm rang each time the staff entered the facility. The staff would proceed to enter the door disabling code and alarm would stop ringing within a few seconds. In an observation on 7/23/14 at 9:35 AM, during rounds with the Maintenance Supervisor, the exit door located at the end of the east side resident hallway (same door Resident #2 utilized to elope) was opened by the milk delivery man who used a code to silence the alarm. The door was propped opened by the milk delivery man. There were no staff members observed to be monitoring the opened door. The Maintenance Supervisor stated, "It's opened because they are doing deliveries." Observation on 7/24/14 at 9:30 AM to 10:40 AM, the exit door located at the end of the east side resident hallway (door utilized by Resident #2 to elope) was opened and the alarm was triggered a total of 5 times. Three CNAs remained seated in the eastside dining room each time the alarm rang. The CNAs did not get up and verify the cause of the door alarm sound. Observation on 7/24/14 at 10:40 AM, LVN D sat in nurse's station on the east side hallway. The exit door at the east side resident hallway (door utilized by Resident #2 to elope) was opened by a staff member and the alarm rang for several seconds. LVN D did not get up from his seat to verify what had triggered the alarm. E. Other Alarmed Doors In an observation on 7/23/14 at 9:30 AM, the Laundry Attendant opened the door on the right side of the main dining room, propped it open with a door stopper, and set the door alarm to delay as she used this door to reach the laundry room. In an interview on 7/23/14 at 9:30 AM, the Laundry Attendant stated she was aware she should not leave the dining room door to the laundry room and maintenance shop opened or set the door alarm to delay. "The people can get out. There are two doors opened to the alley back there, I should not do that." In an interview on 7/23/14 at 11:50 AM, the DON said the door alarm should be on. She said, " The laundry and the CNAs should not put it (the alarm) on delay. " Observation on 7/24/14 at 1:04 PM, the door in the dining room to the laundry area was open and no alarm was sounding. The Comptroller closed the door and yelled to an unseen person to not leave the door open. In an interview on 7/24/14 at 12 Noon, the NHA stated staff could enter the facility using the front door and the exit door located at the end of the east side resident hallway (same door Resident #2 utilized to elope.) Review of Mountain Villa Nursing Center Elopement and Missing Resident Policy (6/15/11) revealed the admitting nurse will assess the resident if they have a tendency to wander out of the facility. Residents that have a history or tendency to wander outside will be monitored closely. Residents susceptible to elopement are ambulatory confused residents, alcoholic residents, generally young residents, sundowners, wheelchair bound that are capable to propel themselves. 2. Exit alarm: all major exit doors leading to the outside are equipped with alarm devices that will sound when the door is open. Alarms must be on at all times. The sound would not stop until it is reset with a password. An IJ was identified on 7/24/14; the Nursing Home Administrator was informed at 2:30 PM. Plan of Removal #4 was submitted by the facility and accepted on 7/25/14 at 6:06 PM.: A. In-service on elopement 4/20/14, 5/14/14,6/17/14,7/24/14,7/15/14-hourly monitoring, redirection activity reorient, reinforce, keep doors closed, answer alarms, call light, place in traffic areas, family visits. B. All wandering Care Plans updated on 7/25/14 C. Ten residents have been identified with wandering risk, interventions are: ? Hourly monitoring ? Elopement monitoring log ? High visibility areas ? Redirection -offer food, water ? Increase activities of their interest D. Residents will be identified by doing Wandering Assessment upon admission, upon change of condition, and every three months. E. Hourly checks for residents who around to be at moderate and high risk for wandering F. Upon first attempt to elopement facility will start discharge planning G. Staff in services on all departments on 7/24/14 and 7/25/14 and q weekly x4 weeks then monthly x4 reinforced then q 6 months to include: ? Employees use front gate as main entry ? Sign by front gate-elopement risk do not let residents go out ? Not using back door by kitchen as entry, use only for throwing trash and delivery ? Kitchen door alarm and door to laundry must be on at all times-do not disarm or delay ? during kitchen deliveries staff must supervise door to ensure that residents do not elope ? Vendors must ring bell for entry for deliveries ? Answer alarms as soon as possible ? keep all doors closed at all times ? Employees who find doors or alarms not working properly must notify maintenance promptly ? Employees must not disable alarm H. Maintenance will check all exits and alarms for proper closure daily I. Administrator has ensured compliance on 7/25/14 and will continue by periodic review, weekly x4, monthly x 4 and q 6 month ' s prn.

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being for 1 (Resident #1) of 12 residents reviewed for pain. The facility failed to protect Resident #1 from unnecessary pain. This failure could place all 21 residents on the West side of the facility at risk of not receiving timely and appropriate care and services. The findings include: Resident #1's Face Sheet dated 06/10/14 indicated Resident #1 was a [AGE] year-old female admitted to the nursing facility on 6/24/09 with [DIAGNOSES REDACTED]. In a physician's progress note dated 5/29/14 the physician documented a [DIAGNOSES REDACTED]. In an interview on 7/14/14 at 3:30 PM, Resident #1 said she has a lot of pain in her legs and hips when she is moved roughly. Resident #1 said Certified Nurse Aide (CNA) A repeatedly hurts her legs when she turns her and provides incontinent care. Resident #1 said she has continuously asked CNA A to be careful with her legs when she moves them because she hurts her. Resident #1 said CNA A would tell her to "shut up" and was not careful turning her or providing incontinent care; she was very rough and caused her increased pain. Resident #1 said this happened over and over even with asking her every time to be careful. Resident #1 said CNA A was the only rough CNA the other CNAs tried to be very gentle with her. In an interview on 7/22/14 at 5:35 AM, CNA A said she had worked at the facility for about 1 month but has a lot of experience and works the 10:00 PM to 6:00 AM shift. CNA A said only 4 residents need turning and incontinent care during the night shift. Resident #1 has contracted legs and complains of pain when you touch her. CNA A said she tells Resident #1 what she is going to do and counts to 3, "1-2-3" and does it. CNA A said Resident #1 complains of pain and I tell her "I have to do it" and then I do it. CNA A denied saying "shut up" to Resident #1. When asked if Resident #1 receives pain medication prior to turning and changing, CNA A said if she asked for pain medicine I would tell the nurse and the nurse would give her something if she asked. In an interview on 7/23/14 at 2:30 PM, CNA Y said Resident #1 has pain all the time from her waist down to her toes. CNA Y said each morning I ask the nurse or medication aide to give her scheduled pain medication before I get her up for her shower or provide care. In an interview on 7/23/14 at 2:55, CNA Z said when he provides care for Resident #1 he is very careful and works very slow so that he doesn't hurt her or cause pain. Review of Resident #1's Physician order [REDACTED]. a. [MEDICATION NAME] 50 mg 1 tablet by mouth twice a day b. Tylenol 325 mg, 2 tablets by mouth 4 times a day as needed for pain. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's As Needed (PRN) record in the computer dated 4/24/2014 to 7/23/2014 revealed Resident # 1 had only been given her ordered PRN pain medication on 5/3/14. Review of Resident #1's All Care Plans dated 12/05/13 documented: Source Library: Chronic pain r/t (related to) Problem: Potential for further pain Approach: Acknowledge presence of pain and communicate interest for well being Instruct resident to inform staff if pain is not relieved Give all supportive medications In an interview on 7/22/14 at 5:55 AM, Licensed Vocational Nurse (LVN) E said he was aware Resident #1 has pain. LVN E said if the CNA tells him she wants something for pain he will give it but no one has reported that she wants something for pain. Review of the facility's undated policy entitled Pain Management revealed in part: C. Pain monitoring is done every shift and charted in the medication record. Review of Resident #1's MAR indicated [REDACTED]. The universe of 21 residents in the West unit was obtained from the census sheet provided by the Nursing Home Administrator on 7/21/14.

Based on interview and record review the facility failed to provide the necessary care and services to 3 (ID #1, #4, #5) of 5 sampled residents to attain or maintain the highest practicable, mental, and psychological well-being in accordance with the comprehensive assessment and plan of care as evidence by: A. Certified Nurse Aide (CNA) #C failed to recognize the signs & symptoms of choking when resident #1 was gasping for air and was cyanotic (slightly bluish, grayish, or dark purple discoloration of the skin). Resident #1 choked while eating his dinner meal. B. The facility failed to follow follow physician's orders [REDACTED]. Resident #4 has a [DIAGNOSES REDACTED]. C. The facility failed to follow physician's orders [REDACTED]. This deficient practice could affect 42 residents that were receiving meal trays by placing them at risk of not receiving the necessary supervision to prevent choking. The findings include: RESIDENT #1 Record revealed Hospital History & Physical dated [DATE] for resident #1 documented resident was a [AGE] year old male with a [DIAGNOSES REDACTED]. Record revealed Hospital Bedside Dysphagia Evaluation dated [DATE] for resident #1 documented in part: NPO (nothing by mouth) assisted with feedings, Upgraded to Mechanical Soft with Thin liquids. Management-1:1 feeding by nursing, Sit upright at 90 angle, Remain upright 30 minutes after eating. Patient low risk for aspiration. Closed record review revealed that resident #1 was initially admitted to the nursing facility on [DATE] and was readmitted from the hospital on [DATE]. Review of the facility's Discharge Summary dated [DATE] documented "resident #1 was alert and oriented X 2, able to recall long-term memory, decision-making is impaired, under guardianship. Usually understood, sometimes with difficulty finding words, responds adequately to simple communication, unclear speech, mumbles words, delusional, supervision with transfers, bed mobility, locomotion on and off unit, dressing, eating, toilet use, personal hygiene, limit assistance with bathing, extensive assist with ambulation in the hallway, continent with bowel & bladder with episodes of incontinence, had a history of [REDACTED]. Had choking episode on [DATE] dinner time, [MEDICATION NAME] maneuver was performed, some food particles came out, verbalized "okay", minutes later went into [MEDICAL CONDITION]. DNR. EMS (Emergency Medical Services) was activated. Final Diagnosis: [REDACTED]. for possible autopsy." Record review revealed Nurses Notes dated [DATE] at 6:05 PM, "Resident #1 in the DR (dining room). Suddenly CNA reported that resident was getting changed (sic). Rushed to DR. Resident #1 looked, getting unconscious, checked if something stuck in his mouth and gave [MEDICATION NAME] maneuver (sic). Resident continued to be getting unconscious, gave oxygen after getting into the room and again gave [MEDICATION NAME] maneuver. Resident showed no change. At 6:15 PM, Resident noted no blood pressure, heart rate nonaudible and no pulse (sic). Pupils fixed and dilated at 6 mm (milliliters) and resident passed away. Late charting 6:25 PM, Notified 911 when resident started getting unresponsive (sic). Paramedics came and they checked the resident's DNR and other documents. Paramedic stated they will be around the premises until police come to the facility (sic). 6:30 PM, called responsible party and left message for the third time to call back. 7:35 PM, Police Officer came to inquire about resident's sudden incident and said he would be calling Medical Examiner." Record review of the Provider's Investigation report provided by Director of Nurses (DON) on [DATE] at 11:50 AM, for resident #1 documented in part: Date of Incident-[DATE] at 6:05 PM. Location-East side Dining Room. Functional Ability-Minimal. Witnesses Certified Nurse Aides (CNA) #B and CNA #C. Description of Allegation: Unexpected Death. Description of Assessment: Resident #1 was cyanotic, minutes after a choking episode, [MEDICATION NAME] maneuver was done, oxygen was administered. EMS was activated. There was not a written witness report attached to the facility's investigation. Record review revealed In-Service Training Record dated [DATE] Topic: Meal Time Supervision. Contents or summary of training. "Continue to: Nurses to go & check the residents while dining. CNAs to be with residents during meal time, to observe closely what's going on. To report to nurse immediately of changes on resident's condition are noted. Nurses to do appropriate measures. Encourage all residents to eat in the dining room so staff can supervise them & provide assistance when needed. Check each tray & deliver it to the right resident." Record review revealed physician's orders [REDACTED]. Supervise feedings all meals. Record review of the facility's Diet List dated February 2011 provided by Food Service Supervisor (FSS) on [DATE] documented in part: Resident #1 Mech Soft-No Bread-Meat Finely chopped. The FSS stated, "Whenever there is a change in the diet orders, I will hand write all of the changes on the current Diet List as I did on this one that is dated February 2011. I give the Diet List to the Director of Nurses (DON). The DON updates the Diet List and prints the updated Diet List on a monthly basis and gives me the updated copy." The FSS confirmed that the Diet Lists dated [DATE] through [DATE] did not document resident #1 should not get bread. Record review revealed Monthly Nursing Summary dated [DATE] for resident #1 documented in part: Eating-Supervision. No setup or physical help. Record review revealed Monthly Nursing Summary dated [DATE] for resident #1 documented in part: Eating-Supervision. Setup help only. Chewing problems. Record review revealed Nutritional Progress Note dated [DATE] QTR (quarterly) review: documented in part: PO (by mouth) intake remains very good, as 100 %, diet was upgraded (while in hospital) to Mech Soft. Record review revealed Nutrition Risk assessment dated [DATE] for resident #1 documented in part: Assess type-Annual. Physical & Mental Functioning-extensive or total assistance or dependent while eating. Requires assist at mealtime. Record review revealed Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #1 documented in part: Eating-Supervision oversight, encouragement or cueing, Setup help only. Swallowing Disorder: Loss of liquids/solids from mouth when eating or drinking. Nutritional Approached: Mechanically altered diet-require change in texture of food or liquids (e.g. pureed food, thickened liquids. Record review revealed Comprehensive Re-entry MDS assessment dated [DATE] for resident #1 documented in part: Eating-Supervision oversight, encouragement or cueing, Setup help only. Swallowing Disorder: Loss of liquids/solids from mouth when eating or drinking. Nutritional Approached: Mechanically altered diet-require change in texture of food or liquids (e.g. pureed food, thickened liquids. Record review revealed Interdisciplinary Care Plan dated [DATE] for resident #1 documented in part: Serve and set up meals. Mech Soft chopped, double portions. Supervise feedings all meals. Supervision during all meals. Meat finely chopped. [DATE] at 1:05 PM, In an interview on [DATE] at 1:05 PM, Licensed Vocational Nurse (LVN) #A on the ,[DATE] shift stated, "We do not have a list of those residents who have swallowing problems. We review the resident's charts & Speech Therapy notes to see if residents have swallowing problems. I randomly check the residents during meals because we have 2 dining rooms. I have not been told that a nurse needs to be in the dining room during meal times. I have 2 CNAs on the East side and 2 CNAs on the West Side. After 5:30 PM, I am the only nurse at the facility. On the East side one CNA will be in the dining room and the other CNA will be checking residents who are eating in their rooms, answering call lights, and assist in the dining room as needed. " LVN #A reported that resident #1 was alert, oriented to person & place, required total assistance with Activities of Daily Living, was incontinent of bowel & bladder, and was able to eat by himself. LVN #A stated, "on [DATE], I was at the nurses station documenting on the MARS (medication administration records). CNA #C came to me and told me that resident #1 was changing. I went to the Dining room in the East side and resident #1 was sitting in the first table on the right side as you enter the dining room. LVN #A stated, "Resident #1 was sitting in his wheelchair, was not coughing, was cyanotic and unresponsive. I did the abdominal thrusts while resident was sitting in his wheelchair. Nothing came out and resident was still unresponsive. Then I stood behind the wheelchair and attempted to do the [MEDICATION NAME] times three. Resident was not coughing and nothing came out of his mouth. I checked and he had a pulse but was getting more cyanotic. The resident was still unresponsive. CNA #B & CNA #C were in the dining room while I was doing the [MEDICATION NAME]. I asked for them to go call the DON. The only thing that I clearly remember is that the DON said to give him oxygen. Then I, DON, and the Med Tech wheeled the resident to the room. I did the [MEDICATION NAME] ,[DATE] times after the resident was started on the oxygen while resident was still sitting in his wheelchair. Resident was now flaccid and not responding. Then the Med Tech & I put the resident in bed. He was more cyanotic and his pupils were fixed and dilated. Oh, I checked the resident's mouth, while he was still sitting in his wheelchair and there was nothing in his mouth. Resident #1 did not have a pulse and no blood pressure when we put him back to bed. Resident had a DNR. We called 911 and when the paramedics arrived we provided them with a copy of the resident's DNR. The police came and said that an investigator from the Coroner's office was coming to facility to determine what had happened to the resident. I heard that resident had another choking episode. I do not know when." In an interview on [DATE] at 2:23 PM, Certified Nurse Aide (CNA) #B reported that he worked on the ,[DATE] shift in the East side on [DATE]. CNA #B reported that there are two CNAs on each side of the facility. CNA #B stated, "on that day I had 3 feeders, so CNA #C was in the dining room. I was feeding resident #3 in her room. I needed a straw so I went to get one from the dining room. This is when CNA #C and a family member who was visiting told me, "there looks like something is wrong with resident #1. I noted that resident #1 was gasping for air and was attempting to motion with his hands that he was choking. I stood the resident up and did the abdominal thrust several times. When I sat the resident down in his wheelchair, I noted a white small piece, approximately the size of a dime of chewed up food on the resident's lap. The resident appeared to be OK and was brushing off the food particle from his pants. The resident was not showing signs of choking when I left the dining room. At that point I left the dining room to go tell LVN #A what had happened with resident #1. I first went to check resident #3 because I had left her laying in bed with her head of the bed elevated because I was in the process of feeding her. So I went to make sure that she was secure in the bed. I was still in resident's #3 room when I heard a lot of noise so I looked out the door to see what was going on. That is when I saw LVN #A and the DON running towards the dining room. The DON asked me to go get the oxygen concentrator from resident's #3 room and take it to the dining room. I did not see when LVN #A did the abdominal thrust or the [MEDICATION NAME] on resident #1. When they wheeled resident #1 to his room, that is when I saw LVN #A was still doing the abdominal thrust while the resident was still sitting in his wheelchair. The DON asked me to check the resident's vital signs. The resident was now unresponsive and had no pulse. LVN #A was still trying to arouse the resident. The resident was not responding. He was dead." CNA #B reported that he did not know if any of the other residents had swallowing problems. In an interview on [DATE] at 3:09 PM, CNA #C reported that she had worked on the ,[DATE] shift on [DATE]. CNA #C stated, "I was in the dining room with a visitor and several other residents. On that day, I was feeding another resident, when I heard Nelson coughing. I noted that CNA #B was in the dining room so I asked him to do the [MEDICATION NAME] on resident #1 because the resident was choking. Resident #1 was a very tall man for me to handle. That is why I, asked CNA #B to do the [MEDICATION NAME]. CNA #B did the abdominal thrust 3 times. I did not see the resident cough anything out of his mouth. We asked the resident if he was OK and he nodded yes. That is when CNA #B left the dining room. I noted that resident #1 again started having a hard time breathing. That is when I went to get the LVN #A. LVN #A and I returned back to the dining room. LVN #A shook the resident and the resident was not responding. LVN #A instructed me to go get the the DON. I told the DON that something was wrong with resident #1. I was right behind the DON when we went to the dining room. The DON was attempting to arouse the resident but the resident was not responding. The DON asked CNA #B to go get the oxygen and to take resident #1 to his room. I saw LVN #A and the Med Tech wheel resident #1 to his room. That was the last time that I saw resident #1." CNA #C reported that the nurse does not specifically assign a CNA to be in the dining room for meals or pass trays. We work together. Trays are served according to the Diet cards. CNA #C stated, "I'm not aware if we have residents with swallowing problems." Telephone interview on [DATE] at 8:39 AM, CNA #C stated," I was in the dining room, but not sitting with resident #1. I was sitting at another table. On that day, the visitor and I just looked at each other because resident #1 looked strange. "His color changed. He was blue. I told the family member, I need to go get the nurse. I was in the hallway and could not see what was going on in the dining room. I did not see if LVN #A did anything else to resident #1, because he sent me out to go get the DON. Resident #1 was not breathing. To me, it sounded like he couldn't breath and was making a very weird sound like he could not breath. I did not check the resident. I just went to get LVN #A." In an interview on [DATE] at 3:42 PM, DON reported that she and the Med Tech were attempting to align the resident in the wheelchair, so LVN #A could do the [MEDICATION NAME]. Nothing came out of resident's mouth. "CNA #C called me to the dining room in the East side, I was working at the Nurses station. When I entered the dining room LVN #A was already working on resident #1. At that point, I asked one of the CNAs to go get the oxygen and take it to resident's #1 room. LVN #A and the Med Tech wheeled resident #1 to his room. I think that LVN #A did another abdominal thrust. The resident remained unresponsive and had no pulse. EMS and the Police were called. The Coroner's investigator came and stated that an autopsy would be done to determine the cause of death. There should always be a CNA in the dining room when the residents are eating. The Nurse will make random checks in the two dining rooms. After 5:30 PM, there is only one nurse in the building." In an interview on [DATE] at 8:56 AM, FSS reported that the DON prints out the monthly Diet List. "Then I will check the physician's orders [REDACTED]. I do this once a month. I keep the Diet list in a clip board in the kitchen. The Diet List reflects the type of Diet, Food & Fluid consistency, Supplements, Portion Size, and any Special instructions for each resident. I randomly go out to check the residents during meal times. The residents are never left alone in the dining room when eating." In an interview on [DATE] at 9:12 AM, Cook #F stated, "We had 3 residents that I was told by the Food Service Supervisor (FSS) should not get bread. I don't think that we have anything written that reflects that. I know that one of those resident was resident #1. The FSS told us, that resident #1 was not suppose to be getting bread because he could not swallow the bread and could choke." In a second interview on [DATE] at 1:42 PM, Cook #F reported that she remember being informed by the FSS, that resident #1 had choked while eating a sandwich prior to the last incident on [DATE]. After the incident with the sandwich, the FSS told us not to serve resident #1 any bread. You would think that others would know, not to give him Burritos." In an interview on [DATE] at 9:25 AM, FSS reported that resident #1 had returned back from the hospital with orders for a Mechanical Soft Diet. The FSS stated, "on one occasion when he had just come back from the hospital, we served resident #1 a sandwich and he had trouble swallowing the bread. That is when we took it upon ourselves not to give him any bread. The resident was able to swallow his food better if the food was not dry so we would put gravy on all his foods. I don't know if the physician was notified that resident #1 had difficulty swallowing breads or foods that did not have gravy." In an interview on [DATE] at 11:25 AM, CNA #G reported that resident #1 would gobble his food and required frequent reminders while eating to slow down. CNA #G stated, "I honestly, can not say that there is always a CNA in the dining room when the residents are eating. I do know that we are there most of the time when the residents are eating." In an interview on [DATE] at 11:13 AM, CNA #H reported that resident #1 was alert, and oriented to person and place. CNA #H stated, "resident #1 was able to eat on his own. He was on a Mechanical Soft diet and never got bread. I was told by someone, I don't remember who, that resident #1 could not eat bread because he would choke." In an interview on [DATE] at 11:05 AM, CNA #I reported that resident #1 was on a Mechanical Soft Diet. "We had to tell resident #1 to slow down when he ate because he ate very fast. He was never served bread. I don't know why." In an interview on [DATE] at 4:16 PM, Consultant Dietitian stated, "I was never told that resident #1 could not have bread. I'm not involved with any of the food preparation or distribution. When a person has an order for [REDACTED]. I do not know if a flour tortilla would dissolve like the bread. The food served on a Mechanical Soft Diet should be bite size. A Dietitian cannot upgrade or down grade a resident's diet. We need a Speech evaluation to do that. In a second interview on [DATE] at 1:42 PM, Cook #F reported that resident #1 on one occasion had apparently choked while eating a sandwich. This is when the FSS told us after this incident, not to give resident #1 any bread. In an interview on [DATE] at 2:20 PM, (LVN) #J reported that resident #1 was alert, and oriented to person and place. The resident was able to eat independently. The resident ate very fast. LVN #J stated "No one every told me resident #1 could not eat bread. The resident had no history of choking." Telephone interview on [DATE] at 3:13 PM, Cook #D reported that they had been instructed by the FSS not to give resident #1, any bread because he could choke. All of the staff knew that resident #1 could not eat bread. "I don't know if this was written anywhere. I know that resident #1 was on a Mechanical Soft diet upon re-admission from the hospital. I did not serve resident #1 Bean Burritos on [DATE]. I served him Chicken Noodles Soup, and Apple Sauce. I don't remember if it was written on the resident's Diet card that he could not eat bread. Resident #1 would open up the meal carts and would take food from the carts. I told the FSS about this. The CNAs do not always serve the right trays to the residents. I reported this to the FSS. I swear to God, that I did not serve resident #1 Burritos on the day of the incident, because I know that he could not eat bread." In an interview on [DATE] at 11:19 AM, visitor reported that she comes to visit her father almost every day for the lunch and dinner meal. The visitor stated," I was in the dining room that day when resident #1 choked. Everyone including resident #1, were served two bean burritos on that day. I was sitting directly behind resident #1 in the dining room. Resident #1 was sitting with CNA #C and another resident. I heard resident #1 making a very strange noise, like if he was trying to clear his throat. Then I noted that the resident was moving his hands towards his chest. I asked CNA #C, do you think that he is choking? CNA #C just sat there at the table and did not do anything to check the resident. At that time, a tall male CNA walked into the dining room and we told him that something was wrong with resident #1. The male CNA checked the resident, stood the resident up and did the [MEDICATION NAME] three times. The resident spit up a piece of burrito. CNA #C asked me, do you thing that resident #1 is choking? Since I was sitting directly behind resident #1, I could not see if the resident continued to eat. I did hear that resident #1 was still making a high pitch sound with his throat and saw that the resident was reaching up to the sky with his arms. At that time resident #1, pushed his wheelchair real hard against my chair. CNA #C was just sitting there at the table and did nothing to assist resident #1. That is when, I told her, you need to go and get help. I saw when a very short, dark nurse named LVN #A came to the dining room. I saw when he shook the resident, to get the resident to respond and checked his pulse. I never saw LVN #A do the [MEDICATION NAME] or the abdominal thrusts on resident #1. I heard when he asked someone, to go get help. I saw when the DON and the Med Tech came to the dining room. I also saw when the DON, LVN #A and Med Tech wheeled resident #1 out of the dining room. I did not see LVN #A, DON, or the Med Tech do the [MEDICATION NAME] on resident #1. I also remember that on that day, the flour tortilla on the bean burritos was very toasted and crispy. I clearly remember that because I was also helping another resident to eat on that day, even though we have been told by the Administration not to do so. I had to practically remove almost all of the flour tortilla because for my father and the other resident because it was very crispy. I had to practically remove almost all of the flour tortilla. I just left enough to hold the beans in place." During the interview it was observed that the visitor's father kept telling her that he was hungry. The visitor told her father we are waiting for the lunch trays, but I have a plate of tacos that I brought for you. It was observed that the visitor put a slice of tomato and thinly sliced cabbage in a small crisp corn tortilla taco. The resident took several bites of the taco and asked for some water. It was observed that the resident started to cough and was moving around in his wheelchair. The visitor asked the resident to spit the food out. The resident continued to cough. The surveyor went to notify LVN #K who was at the nurses station using the telephone. LVN #K immediately went to the resident's room. The resident was drinking water from a cup and was still coughing. LVN #K told the visitor, "your father should not be eating crispy tacos because he is on a Mechanical Soft Diet. He should not be eating cabbage because he cannot chew that and choke." The visitor stated,"I know that my father is on a Mechanical Soft Diet. I am not giving him any cabbage, just the taco, beans, and slice of tomatoes." In an interview on [DATE] at 2:16 PM, LVN #K stated, "one time resident #1 was having difficulty swallowing bread so I gave him some water so he could swallow the bread. Resident #1 never choked on that day, he was just having a lot of difficulty swallowing the bread. I told LVN #J to call the physician to report that resident #1 was not safe eating bread. I also reported this to the FSS and the previous Dietitian. I don't think I documented this in the resident's clinical record. This happened in February 2011. This is when we were informed by the FSS that resident #1 would not be served any bread." In a second interview on [DATE] at 2:37 PM, FSS stated,"I have written on my Diet List dated February 2011, no bread for resident #1." In a second telephone interview on [DATE] at 3:18 PM, LVN #J stated, "I was never told by anyone that resident #1 could not eat bread and to call the doctor. All I know is that resident #1 was never served bread or burritos, but I do not know why." Telephone interview on [DATE] at 9:43 AM, attending physician for resident #1 reported that he was never notified of resident #1 not being able to swallow bread for flour tortillas. The physician reported that he was not aware that the facility staff had taken it upon themselves not to serve bread to resident #1 because he could choke. The physician stated, "They should have notified me of this and we would not have served resident #1 bread, tortillas or other products made with flour. You do know that the resident choked and died . If the facility staff had notified me of this problem, I would have come to evaluate the resident, to see what could be done to address the problem." In an interview on [DATE] at 9:16 AM, MDS Nurse LVN #O confirmed that the Diet card for resident #1 did not document that resident should not get bread. LVN #O confirmed that the Diet card documented "meat finely chopped". LVN #O stated, "I was not aware if resident #1 had swallowing problems." Telephone interview on [DATE] at 10:10 AM, Medical Examiner reported that the direct cause of death of resident #1 was a piece of flour tortilla with beans that was lodged at the opening of the upper Larynx. The Larynx is the enlarged upper end of the trachea (wind pipe) below the root of tongue. In an interview on [DATE] at 10:38 AM, CNA #L reported that resident #1 was oriented to person and place. "The resident was able to eat independently and ate very fast. The resident would take food from other trays. I know that when he was readmitted back, he was getting a Mechanical Soft Diet. I do not believe that resident #1 could eat bread, because they had been told to be on the look out so the resident #1 would not take bread form other residents during meal times." Observation on [DATE] at 8:40 AM, revealed there was a poster in the East Dining Room from the American Red Cross on Steps for Choking Emergencies. The poster documented in part: Adults-if conscious & choking give abdominal thrusts until object comes out or victim is unconscious. If Adult becomes unconscious-Look & remove any foreign object seen in mouth. Give 2 breaths, if air does not go in give 15 chest compressions. If air does not go in, repeat steps 1,2, and 3. If air does not go in, check for signs of circulation. RESIDENT #4 Record review revealed that resident #4 was admitted to the nursing facility on [DATE]. Record review of the Physician Assessment Report from the Managed Care Center dated [DATE] documented resident #4 was an [AGE] year old female with [DIAGNOSES REDACTED]. Medical History: Alzheimer's Dementia, Advanced [MEDICAL CONDITION], Osteopenia, DJD, [MEDICAL CONDITION], [MEDICAL CONDITIONS] Disease, Hypertension, S/P Pacemaker insertion and [MEDICAL CONDITION]. Record review revealed Nutrition Risk assessment dated [DATE] for resident #4 documented in part: Diagnosis: [REDACTED]. Diet Order-High Protein, Finely Chopped, NTL (Nectar Thicken Liquids). Relevant conditions and Diagnoses: [REDACTED]. Physical and Mental Functioning: extensive or total assistance or dependence while eating. 1:1 feeding, check for pocketing. Record review on [DATE] at 2:44 PM, with the DON confirmed that the physician's orders [REDACTED]. SPEECH MANAGEMENT TECHNIQUES-Small bites, No straw, 1:1 Feeding, Check mouth for pocketing. Diet: House Diet. The DON reported that they have 5 residents at the facility that need 1:1 assistance with meals. The DON stated, "when a resident has an order for [REDACTED]. Now because resident #4 has improved a lot, she eats on her own." Review of resident's diet card provided by FSS on [DATE] for resident #4 documented: Mech Soft, finely chopped, crush meds with apple sauce, 1:1 feeding, check mouth for pocketing, small sips, small bites, House Diet, No Straw. Record review of the Medical Nutrition Therapy Assessment from the Managed Care Center dated [DATE] for resident #4 documented in part: Diet: High Protein, Food Prep: Finely Chopped, PO Liquids: Nectar Consistency. Assessment: LVN #K at nursing home report resident with difficulty chewing and swallowing finely chopped food prep. Notify SLP (speech language pathologist) of chewing, swallowing problem. Record review revealed SCU (Special Care Unit) Report from the Managed Care Center for resident #4 dated [DATE] documented in part: Feeding supervise at all times for pocketing. Record review of the Speech Therapy Report dated [DATE] from the Managed Care Center for resident #4 documented in part: PO-SOLIDS Finely Chopped, PO-LIQUIDS Nectar Consistency, Swallowing: Dysphagia. Record review revealed Monthly Nurses Notes dated [DATE] for resident #4 documented in part: Swallowing and Chewing problems. Record review revealed Quarterly MDS for resident #4 documented in part: Swallowing Disorder-Coughing or choking during meals or when swallowing medications. Complaints of difficulty or pain with swallowing. Loss of liquids/solids from mouth when eating or drinking. Record review revealed Interdisciplinary Care Plan dated [DATE] for resident #4 documented in part: Finely Chopped Diet, No bread, No straw. 1:1 feeding assist, cue to swallow, check for pocketing. Observation on [DATE] at 11:36 AM, revealed that resident #4 was eating her lunch meal outside with six other residents sitting her at the same table. There were two CNAs and the DON outside with the residents passing trays and assisting with set up as needed. Resident #4 was eating her meal independently. Facility staff were not providing resident with 1:1 supervision during the lunch meal and were not checking resident for pocketing while the resident was eating. Observation on [DATE] at 8:04 AM, resident #4 was eating her breakfast in the main dining room with three other residents sitting at the table. The resident was observed putting heap spoons of food in her mouth. There were two CNAs passing trays and assisting other residents with set up assistance. Resident #4 was eating her food independently. The CNAs were not providing 1:1 supervision and were not checking resident #4 for pocketing while the resident was eating. In an interview on [DATE] at 12:08 PM, resident's #4 daughter stated, "I come to visit my mother almost on a daily basis. I have seen the CNAs rush my mother to eat. My mother eats very slowly because she had swallowing problems." In an interview on [DATE] at 9:31 AM, MDS LVN #O stated, "when a resident has an order for [REDACTED]. Evidence continued under F9999