Every finding on record at Park Highlands Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) and 1 of 1 residents (Resident #1) reviewed for infection control. The facility failed to ensure the Treatment Nurse performed hand hygiene between glove changes while providing wound care to Resident #1 on 8/5/26. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building.Findings Include:Record review of the face sheet dated 8/5/26 indicated Resident #1 was a [AGE] year-old male who was re-admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a long-term lung disease that blocks airflow and makes breathing hard), Alzheimer's, muscle weakness, Stage IV pressure ulcer (severe, deep wound) of the buttocks, muscular dystrophy (a group of more than 30 inherited genetic disorders that cause progressive muscle weakness and loss of muscle mass over time). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #1 was dependent on staff for toileting and transfers. Record review of the care plan revised on 6/17/26 indicated Resident #1 had an ADL self-care deficit, a pressure ulcer, and potential for pressure ulcer development. During an observation on 8/5/26 at 11:10 a.m. the Treatment Nurse performed wound care on Resident #1. The Treatment Nurse prepared supplies, performed hand hygiene, put on a gown, entered the room, provided privacy, and put on clean gloves. The Treatment Nurse helped Resident #1 get positioned and removed wound dressing from left buttock. The Treatment Nurse removed her gloves, did not perform hand hygiene, and put on clean gloves. The Treatment Nurse cleansed the wound with normal saline and applied collagen powder (an advanced wound care treatment that absorbs fluid and accelerates new tissue growth) to the wound. The Treatment Nurse removed her gloves, did not perform hand hygiene, and put on clean gloves. The Treatment Nurse applied alginate with silver (a specialized, sterile medical wound dressing that absorbs heavy wound fluid while releasing silver to kill bacteria) to the wound and covered the wound with a bordered dressing (a wound covering with a central absorbent pad and an adhesive margin). The Treatment Nurse changed her gloves, did not perform hand hygiene, and put on clean gloves. The Treatment Nurse dated the dressing, gathered her supplies, removed her gown and gloves, and exited the room. During an interview on 8/5/26 at 11:25 a.m. the Treatment Nurse said hand hygiene should be performed before and after wound and incontinent care and between glove changes. The Treatment Nurse said she did not perform hand hygiene between glove changes during Resident #1's wound care because she forgot. The Treatment Nurse said the importance of proper hand hygiene was to prevent the spread of bacteria and to prevent cross contamination. During an interview on 8/5/26 at 12:30 p.m. the ADON said she expected staff to perform hand hygiene prior to providing care, if gloves are changed during care, and before leaving a resident room. The ADON said the importance of proper hand hygiene was infection control. During an interview on 8/5/26 at 12:32 p.m. the Administrator said she expected staff to perform hand hygiene before and after providing care, when gloves were changed, between residents, and when passing meal trays. The Administrator said the importance of hand hygiene was to stop the spread of infections and germs. Record review of the facility's undated Fundamentals of Infection Control Precautions indicated, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.Before and after assisting a resident with personal care.Before and after changing a dressing.After contact with a resident's mucous membranes and body fluids or excretions.After removing gloves or aprons.

Based on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis for 1 of 1 social services staff reviewed for qualifications of Social Worker (SW). The facility failed to employ a SW on a full-time basis. This failure could place the residents at risk of not receiving social services to meet their needs.Record review of the Facility Summary Report from Tulip (Texas Unified Licensure Information Portal) dated 12/31/2018 revealed the facility had a maximum capacity of 132 beds. During a personnel record review on 06/03/2026 the file indicated the SW was hired on 01/31/2022. The record indicated she worked 16 hours per week. During an interview on 06/02/2026 at 4:37 PM, the SW said she only worked 16 hours a week and was employed part time and she was not aware that this facility had to have a full-time social worker During an interview on 06/02/2026 at 4:45 PM, the administrator said the facility was licensed for 132 beds. She said the census had been down, so she had only hired SW part-time.

Based on interview and record review, the facility failed to coordinate the assessment of 1 of 2 residents (Resident #9) reviewed for the pre-admission screening and resident review (PASARR) program and PASARR assessments and evaluations.The facility failed to ensure Resident #9's PASARR Level 1 screening was accurately coded to reflect he had indicators of mental illness.This failure could place residents with psychiatric diagnoses at risk for not being evaluated for PASARR services and potentially not receiving services for care and treatment. Findings included:A record review of a face sheet dated 06/02/2026 indicated Resident #9 was a [AGE] year-old male who admitted to the facility 04/30/2026. He had diagnoses which included PTSD (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) and depression (a serious, common mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). A record review of hospital records dated 04/23/2026 indicated Resident #9 had diagnoses which included PTSD and depression.A record review of the admission MDS dated [DATE] indicated Resident #9 had diagnoses of PTSD and depression. A record review of Resident #9's physician's orders dated 06/02/2026 indicated he had diagnoses of PTSD and depression. A record review of Resident #9's PASRR Level 1 screening dated 04/29/2026 indicated he had no indicators of mental illness.During an interview on 06/02/2026 at 04:12 PM, the MDS Coordinator said she was responsible for ensuring the PASARR Level 1 screening was completed and was accurate. She said she should have noticed Resident #9's PASRR Level 1 screening was incorrectly coded and that it did not reflect he had indicators of mental illness. The MDS Coordinator said she should have notified the local authority about the incorrect PASARR Level 1 screening. The MDS Coordinator said the failure to address the inaccurate PASARR Level 1 screening resulted in Resident #9 not being evaluated for PASARR services and possibly not receiving PASRR services. A review of the facility's policy dated 03/6/2019 and titled PASARR Level 1 Screen Policy and Procedure indicated the following: Procedure: 2. The PL (PASARR Level) 1 Screening Form is completed by the RE (referring entity) using the paper copy of the PL 1 Screening Form. 3. The Facility will review the PL 1 Screening Form for completion and correctness prior to admission and submit the PL 1 form per regulations. and review each item on the PL 1 to ensure accuracy and prevent a regulatory problem.

Based on interview and record review, the facility failed to ensure residents had the right to participate in the development and implementation of his or her person-centered care plan for 3 of 5 dialysis residents (Residents #6, #46, #47) reviewed for the right to participate in planning care.The facility failed to ensure Resident #6, Resident #46 and Resident #47 were included in the development and implementation of their personal care plans.This failure could place residents at risk of not receiving adequate and individualized care while residing at the facility.Findings included:Record review of Resident #6's face sheet dated 06/02/2026 indicated Resident #6 was a [AGE] year-old male and admitted on [DATE] and re-admitted on [DATE]. His diagnoses included ESRD (final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and dependence on renal dialysis (is a type of treatment that helps your body remove extra fluid and waste products from the blood when the kidneys are not able to) and chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). The record indicated Resident #6 was his own responsible party.A record review of a quarterly MDS dated [DATE] indicated Resident #6 had a BIMS score of 15 which indicated his cognition was intact. A record review of doctor orders for Resident #6 indicated dialysis ordered Tuesday, Thursday, and Saturday at a local hemodialysis facility start date of 02/06/2025.A record review of progress notes dated 08/19/2025 to 06/03/2026 for Resident #6 indicated a copy of the baseline care plan was provided to the resident on 08/19/2025. There were no other documentations regarding care plans, care plan meetings scheduled or attended and reflected no documentation the resident had been notified of care plan meetings.A record review of a Care Conference Assessments in the electronic record for Resident #6 indicated the most recent care plan meeting was held on Thursday 03/05/2025. Record review of Resident #46's face sheet dated 06/02/2026 indicated Resident #46 was a [AGE] year-old female and admitted on [DATE] and re-admitted [DATE]. Her diagnoses included ESRD, type 2 diabetes mellitus, and dependence on renal dialysis and acute and chronic respiratory failure (occurs when the lungs cannot release enough oxygen into your blood), major depressive disorder (serious mood disorder that affects how a person feels, thinks, and behaves, often leading to emotional and physical problems). The record indicated Resident #46 was her own responsible party.A record review of a quarterly MDS dated [DATE] indicated Resident #46 had a BIMS score of 15 which indicated her cognition was intact. A record review of doctor orders for Resident #46 indicated renal dialysis ordered Tuesday, Thursday, and Saturday at a local hemodialysis facility with a start date of 02/06/2025.A record review of progress notes dated 12/03/2025 to 06/03/2026 for Resident#46 indicated a copy of the baseline care plan was provided to the resident on 12/03/2025. There were no other documentations regarding care plans, care plan meetings scheduled or attended and reflected no documentation the resident had been notified of care plan meetings.A record review of Care Conference Assessments in the electronic record for Resident #46 in the electronic record indicated the most recent meeting was held on 06/12/2025. Record review of Resident #47's face sheet dated 06/02/2026 indicated Resident #47 was a [AGE] year-old female and admitted on [DATE] and re-admitted on [DATE]. Her diagnoses included ESRD, type 2 diabetes mellitus, and dependence on renal dialysis, and chronic ischemic heart disease (is a long-term heart condition characterized by reduced blood flow to the heart muscle, primarily due to the narrowing or blockage of the coronary arteries. The record indicated Resident #46 was her own responsible party.A record review of a quarterly MDS dated [DATE] indicated Resident #47 had a BIMS score of 15 which indicated her cognition was intact. A record review of doctor orders for Resident #47 indicated dialysis ordered Tuesday, Thursday, and Saturday at a local hemodialysis facility with a start date of 09/10/2021.A record review of progress notes dated 06/12/2025 to 06/03/2026 for Resident #47 indicated no documentation on care plan meetings since the last recertification survey on 06/12/2025 and reflected no documentation that the resident had been notified of care plan meetings.A record review of Care Conference Assessments in the electronic record for Resident #47 indicated no documentation of any care plan conferences held after the last recertification survey on 06/12/2025.During interviews with the resident council on 06/01/2026 at 3:42 PM Residents #6, #46, and #47 stated they would like to be able to attend care plan meetings, and they said they used to go but it had been awhile. They each stated they could not remember when they had last been invited. They agreed to be identified.During an interview on 06/02/2026 at 11:00 AM the SW said care plan meetings were held on Tuesdays for initial care plans and Thursdays for others that were long-term residents. She said residents were notified in person sometimes the day of the care plan meeting. She said she reaches out by phone to notify the families. She said the care plan meetings start around 10:00 AM and those that have dialysis are scheduled earlier around 9:00 AM. She stated documentation of the meeting could be found under care conferences under the assessments tab in the electronic record or in the progress notes. During an interview on 06/02/2026 at 11:40 AM the DON said that care plan meetings were scheduled for Tuesdays and Thursdays and documentation could be found under care plan conferences in the assessments tab. She said she had done them at times depending on who could attend. She said if a resident refused or declined to attend the care plan meeting the social worker noted that information in her notes. She stated she was unsure about when residents receiving dialysis care plan meetings were scheduled. She said Resident #6 and Resident #47 left for dialysis at 6:00 AM and Resident #47 left at 5:45 AM on Tuesdays, Thursdays and Saturdays. She said she did not know if the SW tried to plan meetings on other days or in the afternoons on Tuesday and Thursday.During an interview on 06/02/2026 at 1:57 PM the SW said that notes would be placed in progress notes or care plan conference assessments. She said many residents do not want to attend and when they declined to attend she would chart they had chosen not to come. The SW said she felt the residents would not have harm because they can come to staff anytime when they need things. She stated the nursing staff present at the meetings were responsible for entering the conference note into the electronic record. During an interview on 06/03/2026 8:14 AM the Administrator said that the SW scheduled and notified residents and families of care plan meetings. She said the SW would chart in her progress notes if residents refused to attend. She said Care Conference notes were done by nursing. She said the risk to the residents not being invited to attend care plan meetings would be not getting accurate feedback from the residents about their care and not being able to participate in the meetings.Record review of the undated facility policy Comprehensive Care Planning indicated: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The facility will provide the resident and resident representative, if applicable with advance notice of planning conferences to enable resident participation.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #9) reviewed for care plans.The facility failed to ensure Resident #9's care plan addressed diagnoses of PTSD and depression, and the prescribed use of psychoactive drugs.This failure could place residents with diagnoses of mental illness and psychoactive drug use at risk for not receiving care and services to meet medical, mental, psychosocial, and nursing needs.Findings included:A record review of a face sheet dated 06/02/2026 indicated Resident #9 was a [AGE] year-old male who admitted to the facility 04/30/2026. He had diagnoses which included PTSD (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) and depression (a serious, common mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). A record review of the admission MDS dated [DATE] indicated Resident #9 had diagnoses of PTSD and depression. The MDS: Section V - Care Area Assessment Summary indicated Resident #9 triggered for psychosocial well-being, mood state, and psychotropic drug use. A record review of physician's orders dated 06/02/2026 indicated Resident #9 had orders for 3 (three) psychoactive drugs dated 04/30/2026 which included divalproex sodium 250mg - 1 tablet daily for mood stabilizer, citalopram 40 mg tablet - 1 tablet daily for depression, and trazadone (an antidepressant) 100mg tablet - 1 tablet daily for insomnia. A record review of Resident #9's comprehensive care plan with an initiation date of 05/01/2026 and a completion date of 05/15/2026 indicated there were no documented concerns or interventions to address Resident #9's mental illness diagnoses and psychoactive drug use. During an interview on 06/02/2026 at 04:12 PM, the MDS Coordinator said she was responsible for coordinating the development of the residents' care plans. She said Resident #9's care plan should have addressed his diagnoses of PTSD and depression. She said Resident #9's use of the psychoactive medications, divalproex sodium, citalopram, and trazadone should also have been addressed in his care plan. The MDS coordinator said it was an oversight. She said Resident #9's care plan was important for communicating concerns regarding his diagnosis of PTSD and interventions to address those concerns. During an interview on 06/02/2026 at 04:22 PM, the SW said The MDS Coordinator was responsible for ensuring the care plans were complete and addressed the resident's medical and psychosocial health needs. A record review of the facility's undated policy titled Comprehensive Care Planning indicated the following: The facility will develop and implement a person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following- The surfaces that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychoactive well-being; .

Based on observation, interview, and record review, the facility failed to implement infection control practices designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Residents #42) reviewed for infection control. SA-A did not wash or sanitize her hands, used the same pre-moistened wipe to cleanse multiple areas, and did not change gloves while performing incontinent care for Resident #42 and after disposing of contaminated PPE. SA-A touched clean items with contaminated gloves. SA-A did not remove and dispose of PPE (gown and gloves) and perform hand hygiene before leaving Resident #42's room. These failures could place residents at risk of exposure to and transmission of communicable diseases and infections. Findings included: A record review of a face sheet date 06/02/2026 indicated Resident #42 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included Fournier's gangrene (a rare, life-threatening form of necrotizing fasciitis [flesh-eating disease] that affects the genitals and the area between the genitals and anus) and left buttock pressure ulcer. A record review of the annual MDS dated [DATE] indicated Resident #42 had diagnoses of Fournier's gangrene and a stage IV pressure ulcer of the left buttock. The MDS indicated Resident #42 was incontinent of bowel and bladder, non-ambulatory, and had a BIMS score of 5 indicating his cognition was severely compromised. A record review of Resident #42's physician's orders dated 06/02/2026 indicated he had an order dated 02/06/2026 for Enhanced Barrier Precautions (EBP). The physician's orders indicated Resident #42 had a pressure ulcer on the left buttock. A record review of Resident #42's care plan dated 04/02/2024 indicated he required EBP and included an intervention to perform hand hygiene prior to entering and prior to exiting his room. During an observation and interview on 06/02/2026 at 10:30 AM, SA-A was observed putting on a disposable gown and gloves outside Resident #42's room. SA-A did not wash or sanitize her hands before putting the gloves on. Resident #42 was noted to have an EBP sign posted at the entrance to his room. SA-A said Resident #42 needed incontinent care. SA-A entered Resident #42's room and told him what she was going to do. SA-A folded back bed linen and opened Resident #42's brief to expose his lower body. SA-A obtained a disposable wipe from a bag and used the same wipe to clean both sides of Resident #42's pelvic region and groin area. SA-A placed the wipe in a plastic trash bag lying on the foot of the bag. SA-A then turned Resident #42 to his side, obtained a clean wipe, cleaned his buttocks, and removed the soiled brief from under the resident. SA-A put the soiled brief and wipe into the bag and without changing gloves and performing hand hygiene, SA-A put a clean brief on Resident #42. Still wearing the contaminated gloves, SA-A replaced the bed covers over Resident #42, repositioned his over the bed table, handed Resident #42 his call light and placed the bed control withing his reach. SA-A pulled the room divider curtain back and picked up the plastic bag containing the soiled wipes and brief and left the room while still wearing the PPE (gown and gloves). SA-A walked down the hall, stopped at the common area by the nurses' station, and removed her gloves and gown. SA-A wadded the gown and gloves together and carried the contaminated gown, gloves, and trash bag around the corner to the shower room where she disposed of them. SA-A was observed to leave the shower room without performing any hand hygiene. SA-A said she forgot to obtain a clean wipe each time she moved from cleaning one area of the body to another. She said she forgot to change her gloves before putting on a clean brief on Resident #42. SA-A said she should have removed her gown and gloves while in the resident's room, placed them in the trash bag, and washed her hands. SA-A said she should not have worn the contaminated gown and gloves out of the room. SA-A said she should have washed her hands after she disposed of the trash. SA-A said proper hand hygiene, incontinent care, and PPE use was important for preventing the spread of infection. During an interview on 06/02/2026 at 01:55 PM, SA-B said she was in the nurse aide training program at the facility. She said nurse aides in training could only provide direct patient care if one of the instructors or a certified nurse aide was present. During an interview on 06/02/2026 at 02:12 PM, with the DON and ADON/IP Nurse, the DON said SA-A was in training and was not supposed to provide incontinent care without a Certified Nurse Aide with her. The ADON/IP said she was one of the CNA training instructors. She said she had checked SA-A for skill performance of PPE and Incontinent Care in the skills lab but SA-A needed more training. Both the DON and ADON said proper skill performance of hand hygiene, PPE use, and incontinent care technique were important for preventing the spread of infection. A record review of SA-A's Texas Nurse Aide performance record indicated SA-A rated a satisfactory performance of PPE use on 06/01/2026 in the skills lab and clinical field. SA-A rated a satisfactory performance of incontinent care in the skills lab on 05/27/2026. A review of the facility's policy dated 04/25/2022 and titled Nursing: Personal Care: Perineal Care indicated the following: Procedure Content: 10) Perform hand hygiene11) [NAME] (put on) gloves and all other PPE per standard precautions . 17) .Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke . 24) Doff (take off) gloves and PPE 25) Perform hand hygiene A review of the facility's policy dated 04/01/2024 and titled Enhanced Barrier Precautions indicated the following: How to safely remove personal protective equipment (PPE): Remove all PPE before exiting the patient room except a respirator, if worn. Place the gown and gloves into a waste container. Wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE.

Based on interviews and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 2 residents (Resident #9) reviewed for trauma-informed care. The facility failed to ensure Resident #9 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #9 had a history of trauma. This failure could place residents with a history of trauma at risk for psychological distress due to re-traumatization.The findings included: A record review of a face sheet dated 06/02/2026 indicated Resident #9 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). A record review of the admission MDS assessment dated [DATE] reflected Resident #9 had clear speech and was understood by others. The MDS reflected Resident #9 was able to understand others. The MDS reflected Resident #9 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS reflected Resident #9 had no behaviors or refusal of care. The MDS reflected Resident #9 had an active diagnosis of PTSD. A record review of Resident #9's initial social history dated 05/12/2026 indicated the trauma informed care section was not completed until 06/02/2026 after surveyor intervention. During an interview on 06/02/2026 at 04:22 PM, the SW said she was responsible for completing the Trauma Informed Care section of the Social History Assessment. The SW said she went by the PASARR completed by the hospital and did not notice Resident #9 had a diagnosis of PTSD in the hospital records and on facility's admission records. The SW said she did not notice that Resident #9 triggered for PTSD, psychosocial well-being, and mood state on the admission MDS dated [DATE]. The SW said it was important to ensure residents were screened for a history of trauma and potential triggers were identified to minimize or prevent triggers that could cause re-traumatization. A record review of the facility's policy titled Trauma Informed Care dated October 2022 indicated the following: The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.Assessment: Facilities should use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences. This would include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument, admission Assessment, the history and physical, the social history/assessment, and others.

Based on observations, record review, and interviews, the facility failed to have a governing body who appointed a licensed administrator for 1 of 1 facilitiy reviewed for governing body.The facility did not have a licensed administrator since 09/22/2025.This failure could affect the safety and overall wellbeing of the residents and day-to-day operation of the facility.Findings included:During an interview on 11/13/2025 at 9:10 AM, the Administrator-in-training said she was the current administrator but did not have a license. She said the previous administrator was at the facility until sometime in September 2025. She said she had a corporate administrator who was not currently in the building and was not aware that a licensed administrator had to be in the building.During an interview on 11/13/2025 at 9:10 AM, the Administrator-in-training said she had called the corporate administrator to ask him if he could come by the facility and the corporate administrator told her he was in another facility who also had the state surveyors in another building. The Administrator-in-Training did not know the corporate administrator would not be coming in to work.During an interview on 11/13/2025 at 11:20 AM, the Administrator in Training said the corporate administrator had not worked 40 hours per week consistently in the facility since she started at the facility on September 22, 2025. She said he talked with him on the phone for his input. She said she was not aware that a license administrator had to be in the building for 40 hours 5 days a week. During an interview on 11/13/2025 at 12:45 PM, the Maintenance Supervisor said, the administrator of record had not been in the facility consistently for 40 hours per week since the Administrator in Training had been there since 9/22/2025, he said they did not have an Administrator in the facility regularly, he said the Administrator in Training had not fully completed her course work and was not eligible for state administrator licensure testing until completed.Upon request for human resource records, the HR department head was not present during the survey and there was no one else to obtain records.During an interview on 11/13/2025 at 12:55 PM, the DON said the corporate administrator had not been in the facility consistently for 40 hours per week since the Administrator in Training has been here 9/22/2025. She said he checks in by phone with the Administrator in Training.During an interview on 11/13/2025 at 1:30 PM, the Corporate Director of Nurses said she could not come up with documentable evidence of an administrator being physically present in the facility for 40 hours weekly. She said she was not aware that a license Administrator had to be in the building that many hours and days. She stated she would confirm and get back with the surveyor.During an interview on 11/13/2025 at 2:00 PM, the facility Social Worker said she has not seen the Corporate Administrator in the building in weeks.During an interview on 11/13/2025 at 2:30 PM, the Administrator in Training said, her first day was 09/22/2025. She said she found out she had one more required course to take, and it would not be completed until December 2025. She stated, then, she would be able to schedule for her test for the state administrator license.Record review of a printed staff roster, dated 11/13/2025 at 10:15 AM, revealed no licensed Administrator was listed.During observations throughout the complaint investigation survey (11/13/2025 from 8:30 AM to 11/13/2025 4:00 PM) the administrator listed on the provided information for an on-site visit was not present in the facility

Based on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 4 residents (Resident #35) reviewed for gastrostomy tube management. The facility failed to ensure Resident #35 was provided with the correct feeding administration set up (no name, date or feeding being administered) through gastrostomy tube (g-tube, feeding tube). This failure could place residents who received feedings by gastrostomy tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health, weight loss and poor wound healing. Findings: Record review of Resident #35's face sheet, dated 05/5/2025, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with and readmitted on [DATE] with diagnoses to include Cerebral infarction affecting right dominant side, Dysphagia (or difficulty swallowing), subsequent encounter, Aphasia(is a communication disorder that results from damage to the brain's language centers, usually due to a stroke or brain injury), type 2 Diabetic Mellitus, alcohol abuse, other seizure, Chronic Respiratory Failure with Hypoxia(is a condition where the body or a specific region of the body doesn't receive enough oxygen at the tissue level), Subsequent encounter, and gastrostomy status (g-tube). Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #35's, BIMS score of 9(score of 9 falls within the range indicating moderate cognitive impairment. This suggests the individual may need some extra assistance with daily activities or specific tasks and may be experiencing cognitive decline). The MDS further documented Resident #35's Nutritional Approach While a Resident was feeding tube. Attempt interview 5/4/2025 at 10am, with Resident #35 who could not describe his feeding set up that was hanging on pole beside his bed was unaware tube feeding. Record review of physicians' orders of Resident #35 reflected he requires a tube feeding r/t (related to) dx (diagnosis) of dysphagia; Focus: The resident requires tube feeding r/t dysphagia. Observations for of Resident #35's feeding revealed: *5/4/2025 at 09:43 am G-tube feeding administration set hanging on pole with feeding in bag not running no labels of name, date or time. *5/4/2025 at 10:30 am G-tube feeding administration set continues to hang with no date or time *5/4/2025 at 12:00 pm G-tube feeding administration set continues to hang with no date or time. During an interview on 5/4/2025 at 12:15PM with RN A revealed that Resident #35 feeding was off because his feeding G-tube feeding 9pm - 9am but it should have a date, time, and name of resident on the feeding set up. During an interview on 5/4/2025 at 12:30PM with RN B who was the week-end charge nurse revealed that Resident #35's feeding had no date, time, and name of resident on the feeding set up. During an interview with Corporate RN on 5/4/2025 at 1:00PM she stated she was unsure why Resident #35's feeding pump did not have a date, time and name on the administration set., She said, it was the company policy to label feeding with name, date, and time. The Corp RN stated, the nurses are trained to check the feeding pump rate when new bags of formula are hung. The Corp RN stated the potential negative outcome to the residents were (5 Rights). Right drug: compare label to doctor's order. Right patient: identify using two identifiers. Right dose: confirm appropriate dose. Right route: correct method of administration (oral, .) Right time: adhere to frequency as prescribed. The Corp RN was asked for policy on Enteral Feeding. Record Review of Gastrostomy Tube Care Policy dated Rev. February 13, 2007: 11.labeling/Dating - formula and or feedings should be labeled with at least the date and time the administration began. Canned or bottled feeding that are opened and poured into and administration set should be changed every 24 hours.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 3 of 3 shower rooms reviewed for environment. (North Wing, East Wing and Rehabilitation hall). The facility failed to ensure the shower rooms on the North Wing, East Wing and Rehabilitation hall were free of a black substance in between the tiles. This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: During an observation on 03/25/24 at 2:02 p.m., the Rehabilitation hall shower room had a dark black substance, about 3 inches in length on the right wall and a dark black substance, about 2 inches in length, on the back wall of the shower in between the grout where the wall tile and floor tile met. During an observation on 03/25/24 at 2:23 p.m., the East Wing shower room had two showers. The shower furthest from the door had a dark brown and black substance, about 3 inches in length, on the left wall of the shower in between the grout where the wall tile and floor tile met. During an observation on 03/25/24 at 2:30 p.m., the North Wing shower room had three showers. The shower closest to the door had a black substance, about 4 inches in length, on the right wall of the shower in between the grout where the wall tile and floor tile met. During an interview on 03/25/24 at 3:04 p.m., the HSKS said she managed housekeeping and was responsible for the cleanliness of the facility. The HSKS said housekeeping staff cleaned the showers daily and as needed. The HSKS said she made rounds to ensure her staff cleaned their assigned areas appropriately. The HSKS said she believed the black substance was mold. The HSKS said for the past two months she had worked the floor due to staffing and was unable to make her rounds like she should during that time. The HSKS said they had a position open for a full-time housekeeper and are currently looking to hire someone for it. Record review of the facility's Deep Cleaning Process-Bathroom/Showers dated 2015 indicated, .1. Starting in a clockwise motion from bathroom/shower door; dust, clean, polish, scrub, scrape, everything in the room including but not limited to: .3.begin cleaning, scrubbing .b. walls: clean all walls, including shower or tub walls .j. Floors .

Based on observations, interviews, and record reviews, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 3 residents (Residents # 216 and 218) reviewed for care plans. The facility failed to address, in Resident #216's baseline care plan, his indwelling urethral catheter (tube inserted through the urethra into the bladder and left there to drain the urine), his diagnoses of Acute Renal Failure (condition in which the kidneys suddenly cannot filter waste from the blood), Inflammatory Reaction Due to Indwelling Urethral Catheter (urinary tract infection due to presence of an indwelling urethral catheter), Retention of Urine (condition wherein the bladder does not empty completely or not at all), and his antibiotic therapy (medication given to treat an infection) upon admission to the facility. The facility failed to address, in Resident # 218's baseline care plan, her cervical collar (a rigid device that is placed around the neck and extends from the base of the neck to the top of the back to prevent movement of the neck) and her diagnosis of Nondisplaced Fracture (one in which the bone cracks or breaks but retains its proper alignment) of 5th Cervical Vertebra (bone in the neck) upon admission to the facility. These failures could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met, promote health, and prevent a decline or injury. Findings included: Resident #216: Record review of Resident #216's face sheet dated 03/27/2024 indicated he was an [AGE] year-old male who admitted on [DATE] with diagnoses which included Covid and discharged home on 02/29/2024. The face sheet further indicated Resident #216 readmitted to the facility on [DATE] with new diagnoses of Acute Renal Failure, Inflammatory Reaction Due to Indwelling Urethral Catheter, and Retention of Urine. An in progress MDS dated [DATE] documented Resident #216 to have a BIMS score of 10, indicating his cognition to be moderately impaired. Record review of Resident #216's physician orders dated 03/25/2024 indicated instructions for the care of a urethral catheter and administration of an antibiotic medication (Bactrim DS twice daily). Record review of Resident #216's baseline care plan did not reflect any concerns, goals, interventions, nor instructions to address the presence of a urethral catheter, nor the physician's orders for catheter care. The baseline care plan did not address Resident #216's recent diagnoses of acute renal failure and infection associated with the use of an indwelling urethral catheter nor the prescribed antibiotic therapy to treat the urinary infection. During an observation and interview on 03/25/2024 at 10:57 AM, Resident #216 was noted transferring from his wheelchair to his bed. He said he was returning from therapy. Resident was observed to have a clear tube coming out of the front opening of his pajamas and draining into a closed collection bag inside a privacy covering. Resident said a doctor put in a tube in his bladder because he could not urinate. He said the catheter had to stay until he saw the doctor again. He said he had an appointment, but he couldn't remember who the doctor was nor when his appointment was. He said his family took care of those things. During an interview with LVN B on 03/27/2024 at 10:52 AM, she said Resident #216's urethral catheter was to stay in place until he saw the urologist and he was to be given Bactrim DS twice a day for 7 (seven) days for treatment of the urinary tract infection. LVN B said she could not locate any information in Resident #216's care plan that addressed his catheter, his diagnoses of acute renal failure, urinary infection, and urine retention, nor his antibiotic therapy. She said the purpose of a care plan was to ensure a resident's needs were managed properly and consistently. During an interview with the DON on 03/27/2024 at 11:10 AM, she said Resident #216's care plan from his previous stay at the facility (02/24/24-02/29/24) was re-activated by LVN C as his baseline care plan for his current admission on 03/18/2024. She said the care plan did not address Resident #216's antibiotic therapy, urethral catheter, and the new diagnoses of acute renal failure, urinary tract infection, and retention of urine. She said the diagnosis of acute renal failure associated with a urinary tract infection caused by the urethral catheter was the primary reason for Resident's admission and should have been addressed in the baseline care plan. The DON said that she and the ADON were responsible for reviewing the admission care plans. She said she was the nurse who reviewed Resident #216's baseline care plan. LVN C was not available for interview. Resident #218: Record review of Resident #218's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Non-displaced Fracture of the 5th Cervical Vertebra (fracture of a bone in the neck). An in progress MDS dated [DATE] documented Resident #218 to have a BIMS score of 14, indicating her cognition to be intact. During observation and interview on 03/25/2024 at 11:05 AM, Resident #218 was noted to be sitting in a high back wheelchair in her room with a rigid cervical (neck) collar lying on the table beside her. She said she had just taken it off. She said she had fallen at home and broken her neck. CNA E entered the room and said she would tell the nurse about the neck brace. During observation of Resident #218 at lunch on 03/25/2024 at 12:10 PM, she was observed to be wearing the cervical collar and having difficulty feeding herself. She said she did not want any help and added that she wasn't hungry anyway. During an interview with the Speech Therapist (ST) on 03/27/2024 at 10:52 AM, she said Resident #218 was supposed to wear the cervical collar when she was sitting up. During an interview with LVN B on 03/27/2024 at 10:58 AM, she said Resident #218 was supposed to wear the cervical collar when she was out of the bed. She said Resident #218 was not compliant with wearing the collar. LVN B said she thought she read the directions for the collar use in the chart, but she could not find a physician's order for it. She said the nurses relied on information shared during change of shift report to know resident specific needs. A review of Resident #218's physician orders dated 03/27/24 did not reveal a physician's order for a cervical collar nor any instructions for the use or care of it. Review of Resident #218's baseline care plan dated 03/18/2024 did not indicate any concern, focus, goals, nor interventions for the cervical collar. During an interview with the DON on 03/27/2024 at 11:10 AM, she said she was aware of Resident #218's neck fracture and knew she was to wear a cervical collar when out of bed before the Resident admitted to the facility. The DON provided a copy of a physician's progress notes dated 03/12/2024 from the hospital's clinical records that indicated Resident #216 would need lots of help upon discharge and that she is significantly incapacitated by needing to wear the cervical collar. She said the ADON initiated Resident #218's baseline care plan and said the care plan should have addressed the cervical collar and Resident 218's diagnosis of non-displaced fracture of the 5th cervical vertebra. The DON confirmed that neither the physician's orders nor the care plan addressed the use of a cervical collar. She agreed that Resident #218's baseline care plan should have included interventions to promote healing and prevent decline or further injury. During an interview about Resident #218's baseline care plan with the ADON on 03/27/2024 at 11:15 AM, she said she overlooked the diagnosis of a fractured vertebra and the cervical collar. She said both the fracture and the collar should have been addressed in the care plan. Review of the facility's policy titled Base Line Care Plans indicated the following: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . The baseline care plan will reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident from the transferring provide, and discussion with the resident and resident representative, if applicable.

Based on interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR) Screening for 1 of 5 residents reviewed for PASRR (Resident #48). The facility failed to ensure Resident #48 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 06/30/2023. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of an undated face sheet indicated Resident #48 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including anxiety, high blood pressure and diabetes. Record review of the admission MDS assessment dated [DATE] indicated, Resident #48 had a BIMS score of 14 (fourteen) indicating no impaired cognition. The MDS section for PASRR (A1500) indicated Resident #48 did not have a serious mental illness. The MDS section, Active Diagnoses Psychiatric/Mood Disorder, indicated Resident #48 to have diagnoses of anxiety disorder, depression, and bipolar disorder. Record review of physician orders current as of 03/27/2024 indicated an order dated 10/29/2022 for Resident #36 to receive one (1) buspirone 15 mg tablet two times a day for anxiety and an order dated 07/19/2023 for one (1) fluoxetine 40 mg tablet for depression one time a day. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #48 was receiving antianxiety and antidepressant medications on a routine basis. Record review of Resident #48's PASRR Level 1 Screening completed on 06/20/2023 indicated in section C0100 this resident did not have evidence of having a mental illness. Record review of Resident #48's initial psychiatric evaluation visit dated 08/15/2023 indicated the resident had major depressive disorder and anxiety disorder. The psychiatric evaluation/management visit dated 02/20/2024 indicated the resident had diagnoses of bipolar disorder, depression and sleep disturbances. Record Review of Resident 48's admission face sheet and physician orders from the discharging facility dated 06/13/2023 indicated the resident had diagnoses including bipolar disorder, depression and anxiety. During an interview with the MDS Nurse on 03/27/2024 at 1:30 PM, she said she was responsible for tasks related to PASRR and MDS processes. She said she was not the MDS Coordinator at the time of Resident #48's admission. She viewed the admission PASRR and said the discharging long term care facility had sent an inaccurate PASRR Level 1 Screening indicating the resident was negative for mental illness. She said the LA (Local Authority) was not notified of the incorrect PASRR. Record review of facility policy PASRR Level 1 (PL1) Screen Policy and Procedure, revised 03/06/2019, indicated .reviewed for correctness .to ensure accuracy and prevent a regulatory problem.

Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain weight and health 1 of 8 residents (Resident # 15) reviewed for hydration. The facility failed to ensure Resident #15 received a daily nutritional supplement. This failure could place residents at risk for unplanned weight loss, malnutrition, and failure to thrive. Findings included: Record review of the Quarterly MDS dated [DATE] indicated Resident #15 was understood and understood others. Resident #15's BIMS score was 15, indicating she was cognitively intact. Record review of a face sheet dated 03/27/2024 indicated Resident #15 was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of acute combined systolic (congestive) and diastolic (congestive) heart failure, dysphagia (difficulty swallowing), oropharyngeal phase (middle part of throat behind the mouth) and muscle weakness (generalized). Record review of Resident's #15 doctors order, dated 02/13/2024, indicated Resident #15 will receive a supplement frozen treat, daily, at lunch. Record review of Resident #15's dietary profile, with an effective date of 03/04/2024, indicated Resident #15 did not gain any weight in the past 6 months. Record review of Resident #15's weights, over the past 6 months, indicated Resident #15 had a weight loss of 14.8 pounds, in the past 6 months. Which was an 8% weight loss in 6 months. 02/05/2024 . 159.2 Lbs .wheelchair 01/03/2024 . 162.4 Lbs .wheelchair 12/06/2023 . 165.2 Lbs .wheelchair 11/01/2023 . 159.2 Lbs .wheelchair 10/04/2023 . 169.0 Lbs .wheelchair 09/04/2023 . 174.0 Lbs .wheelchair Record review of the comprehensive care plan, with a review date of 12/18/2023 indicated Resident #15 had a regular diet order, is at risk for unplanned weight loss related to diabetes, dysphagia and malnutrition. The care plan goal for Resident #15: will maintain ideal weight and receive proper nutrition daily, X 90 days. Record review of Resident #15's nutritional assessment, with an effective date of 03/26/2024; risk factor #15, indicated Resident #15 was receiving a nutritional supplement. During an observation and interview on 03/26/2024 at 10:52 a.m., Resident #15 was sitting at a table in the dining hall, eating her noon meal. Resident#15's meal ticket indicated she was to receive a supplement, 4 oz magic cup. When asked, Resident #15 said she did not receive a magic cup. She said she the last time she received a magic cup was one day last week. During an observation and interview on 03/26/2024, at 10:56 a.m., the Marketer was observed picking up and removing meal trays from tables in the dining hall. When asked if Resident #15 received a magic cup, the Marketer, looked at Resident #15's meal tray, observed her meal ticket and said, no, she did not receive it. During an interview on 03/26/2024 at 12:50 a.m., when asked if Resident #15 received a magic cup with her noon meal, the Dietary Manager said, no, it was an oversight. She said it was really busy in the kitchen, temperatures of the foods were being taken and she was having to fill in for another dietary staff. She said the DON was checking the trays before they were taken to the dining hall. She said she would take Resident #15 a magic cup. During an interview on 03/27/2024 at 1:49 p.m., the DON said she checked the resident trays as they came out of the kitchen. She said she could not tell this surveyor if Resident #15 received a magic cup or not. She said she could not remember. She said could not remember if Resident #15 had a red glass on her tray, which would indicate, Resident #15, was to receive a dietary supplement. Record review of a Dietary Services Policy & Procedure Manual, dated 2012, did not indicate any policy or procedure the facility would take to assure residents receive a nutritional supplement.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #23) reviewed for smoking. The facility failed to ensure the Safe Smoking Assessment was completed and implemented for Resident #23. The failure placed residents at risk of cigarette burns and unsafe smoking conditions. Findings included: Record review of the Face sheet indicated Resident #23 was a [AGE] year-old male, admitted on [DATE], with diagnoses of pneumonia, chronic obstructive pulmonary disease with acute exacerbation (obstructed airflow from the lungs caused by inflammation), chronic viral hepatitis C (viral infection that affects the liver causing inflammation), acute cystitis (inflammation of the urinary bladder), hypo-osmolality and hyponatremia (low sodium levels in the blood), alcoholic cirrhosis of the liver (scar tissue on the liver caused by alcohol consumption), wedge compression fracture of the second and fourth lumbar vertebra (one side of the vertebra collapses), and muscle weakness (generalized). Record review of Resident #23's MDS dated [DATE] revealed he had a BIMS (Brief interview for Mental Status) summary score 13 indicating he was cognitively intact. Record review of Resident #23's care plan dated 03/22/2024 indicated he was a smoker and interventions included a smoking assessment monthly and to smoke in designated areas under supervision of a visitor or facility staff member. Record review of Resident #23's medical chart revealed there was no smoking assessment in his chart. During an observation and interview on 03/25/24 at 11:05 a.m., Resident #23 was outside in the designated smoking area. Resident #23 said he had been smoking for about [AGE] years. Supply employee G was in the designated smoking area monitoring the residents. Supply employee G provided distributed cigarettes, provided smoking aprons and assisted the residents with lighting their cigarette. Supply employee G said the smoking times are posted on activity room bulletin broad and she had been assigned supervising residents in smoking area for over one year. Resident #23 was not provided a smoke apron. During an observation and interview on 03/25/24 at 11:30 a.m., the DON said the Smoking Policy was posted in the entry hallway and is a part of the admission packet. The Smoking Policy and smoking times were posted in the entry lobby. During an observation and interview on 03/26/24 at 11:32 a.m., Resident #23 was in the hallway going toward the activity room in his wheelchair. Resident #32 was wearing blue jeans with burn marks on them. Resident #23 said his blue jeans were old and he had been a smoker for [AGE] years. During an observation and interview on 03/27/24 at 10:30 a.m., LVN B reviewed Resident #23's electronic health records for a smoking assessment. LVN B said there was no smoking assessment in Resident #23's chart. During an observation on 03/27/24 at 11:00 a.m., Resident #23 was outside in the designated smoking area. Supply employee G was in the designated smoking area monitoring the residents smoking Resident #23 was not provided a smoke apron. During an interview on 03/27/24 at 3:00 p.m., the DON reviewed Resident #23's electronic health records for a smoking assessment. The DON said there was no smoking assessment in Resident #23's chart. The DON said she would complete Resident #23's smoking assessment and have it in his chart today. Record review of the facility's Smoking Policy indicated, A Safe Smoking Assessment will be done regularly for each resident who smokes .

Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 13 of 15 residents reviewed for pharmacy services. (Residents #2, #12, #14, #18, #20, #24, #28, #29, #31, #38, #248, #249, #251). The facility did not administer all medications to Residents #2, #12, #14, #18, #20, #24, #28, #29, #31, #38, #248, #249, #251. These residents did not have some medications available for administration. This failure could place residents at risk of not receiving their medications as ordered. Findings included: Resident #2 A review of Resident #2's clinical record indicated the Resident was admitted to the facility on [DATE] with diagnoses including: chronic kidney disease, anxiety disorder, unspecified protein-calorie malnutrition, high blood pressure, type 2 diabetes, spinal stenosis, muscle wasting and atrophy, and schizoaffective disorder. A review of Resident #2's physician orders dated 12/23/22 indicated the Resident had orders for Carvedilol (hypertension)12.5 mg two times a day, Atorvastatin(cholesterol) 40 mg at bedtime, renal multivitamin tablet B complex and C folic acid one time a day, and tizanidine hydrochloride (muscle relaxer) 2 mg two times a day. A review of Resident #2's MAR dated 01/01/23 through 01/31/23, indicated she did not receive Carvedilol on 01/13/23, she did not receive renal multivitamin on 01/31/23. Progress notes dated 01/13/23 and 01/31/23 indicated the medications were not available. A review of Resident #2's MAR dated 02/01/23 through 02/28/23, indicated she did not receive renal multivitamin on 02/02/23, 02/03/23 and 02/06/23, she did not receive tizanidine hydrochloride on 02/07/23 and 02/08/23 and she did not receive Atorvastatin on 02/10/23. Progress notes dated 02/02/23, 02/03/23, 02/06/23, 02/07/23, 02/08/23 and 02/10/23 indicated the medications were not available. Resident #12 A review of Resident #12's clinical record indicated the resident was admitted to the facility on [DATE] with the following diagnoses: atrial fibrillation, high blood pressure, heart failure, dysphagia, alcohol use, dementia, anxiety, and major depressive disorder. A review of Resident #12's physician orders dated 02/15/23 indicated the resident had orders for Apixaban (anticoagulant used to prevent blood clots) 5 mg, two times a day; Famotidine (heart burn) 20 mg, one time a day and Spironolactone (for heart failure, high blood pressure and swelling) 50 mg, one time a day in the morning. A review of Resident #12's MAR dated 01/01/23 through 01/31/23, indicated he did not receive Spironolactone on 01/05/23, evening dose of Apixaban on 01/12/23 and morning dose of Apixaban 01/13/23. Progress notes dated 01/05/23, 01/12/23 and 01/13/23 indicated the medications were not available. A review of Resident #12's MAR dated 02/01/23 through 02/28/23, indicated he did not receive Famotidine on 02/07, 02/08, and 02/09. Progress notes dated 02/07/23, 02/08/23, and 02/09/23 indicated the medications were not available. Resident #14 A review of resident #14's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: psychotic disturbance, mood disturbance and anxiety, muscle wasting, major depressive disorder, history of urinary (tract) infections, hypothyroidism(lack of thyroid hormone), osteoarthritis(tissue that is worn down), and metabolic encephalopathy (delirium and acute confusional state). A review of Resident #14's physician orders dated 02/15/23 indicated the resident had orders for levothyroxine (lack of thyroid hormone) 50 mcg in the morning, meloxicam (for pain) tablet 15 mg in the morning, lidocaine external patch (for pain) 4% at bedtime, Macrobid (for UTI) 100 mg and cefuroxime axetil (antibiotic) 500 mg 2 times a day. A review of Resident #14's MAR dated 01/01/23 through 01/31/23, indicated she did not receive levothyroxine on 01/24/23, she did not receive meloxicam on 01/24/23, 01/25/23, 01/26/23, 01/27/23, 01/30/23 and 01/31/23. Progress notes dated 01/24/23 indicated the medications were not available. Progress notes dated 01/25/23, 01/26/23, 01/27/23, 01/30/23 and 01/31/23 indicated the medication was not available. A review of Resident #14's MAR dated 02/01/23 through 02/28/23, indicated she did not receive these medications on the following dates: *Lvothyroxine on 02/03/23, 02/07/23, 02/08/23 and 02/09/23, *Meloxicam on 02/01/23, 02/02/23, 02/03/23, 02/08/23, 02/09/23 and 02/10/23, *Cefuroxime axetil on 02/07/23 and 02/08/23, *Macrobid on 02/08/23, 02/09/23 02/10/23, and *Lidocaine patch on 02/13/23. Progress notes dated 02/01/23, 02/02/23, 02/03,23, 02/07/23, 02/08/23, 02/09/23, 02/10/23 and 02/13/23 indicated the medications were not available. Resident #18 A review of Resident #18's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: diabetes, atrial fibrillation, high blood pressure, indigestion, schizophreniform disorder (non-permanent psychotic disorder), stroke, anxiety, and depressive disorder. A review of Resident #18's physician orders dated 02/15/23 indicated the resident had orders for folic acid (vitamin supplement) 1 mg. one time a day, Lisinopril (blood pressure medication) 10 mg. every morning, potassium chloride (a supplement) 10 MEq. every morning, Seroquel (for schizophreniform disorder) 25 mg. a bedtime, and Zoloft (for depressive disorder) 50 mg. 1.5 tablets every morning. A review of Resident #18's MAR dated 01/01/23 through 01/31/23, indicated she did not receive Zoloft on 01/03/23 and did not receive Lisinopril and potassium chloride on 01/09/23. Progress notes dated 01/03/23 and 01/13/23 indicated the medications were not available. A review of Resident #18's MAR dated 02/01/23 through 02/28/23, indicated she did not receive Lisinopril on 02/03/23, did not receive folic acid and Lisinopril on 02/08/23, did not receive Lisinopril on 02/10/23, did not receive folic acid and Seroquel on 02/13/23. Progress notes dated 02/03/23, 02/08/23, 02/10/23, and 02/13/23 indicated the medications were not available. Resident #20 A review of Resident #20's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: heart failure, high blood pressure, atrial fibrillation (irregular heart rate with reduced blood flow), mood disturbance and anxiety, delusional disorders, psychotic disturbance, and dementia without behavioral disturbance. A review of Resident #20's physician orders dated 01/01/23 indicated the resident had orders for colchicine(anti-inflammatory) 0.6 mg 1 tablet in the morning, Lasix (diuretic) 20 mg one time a day, sotalol (for irregular heartbeat) 80 mg one time a day, hydroxyzine (antihistamine) 50 mg two times a day and Lexapro (antidepressant) 0.5 mg in the morning. A review of Resident #20's MAR dated 01/01/23 through 01/31/23, indicated she did not receive colchicine 01/09/23 and 01/11/23. She did not receive Lasix on 01/08/23 and 01/10/23, she did not receive hydroxyzine on 01/09/23 and she did not receive Lexapro on 01/09/23 and 01/10/23. Progress notes dated 01/08/23, 01/09/23, 01/10/23 and 01/11/23 indicated the medications were not available. Resident #24 A review of Resident #24's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: post-traumatic stress disorder, diabetes, dementia, anxiety, sleeplessness, indigestion, and major depressive disorder. A review of Resident #24's physician orders dated 02/15/23 indicated the resident had orders for donepezil (for dementia) 10 mg. daily, furosemide (diuretic) 40 mg. one time a day, Linzess (for constipation) 145 mcg. one time a day, and Lisinopril (for blood pressure) 2.5 mg. one time a day. A review of Resident #24's MAR dated 01/01/23 through 01/31/23, indicated she did not receive furosemide on 01/11/23, 01/12/23, and 01/13/23 and did not receive Lisinopril on 01/23/23. Progress notes dated 01/11/23, 01/12/23, and 01/13/23 and 01/13/23 indicated the medications were not available. A review of Resident #24's Medication Administration Record (MAR) dated 02/01/23 through 02/28/23, indicated she did not receive Linzess on 02/09/23 and did not receive donepezil on 02/14/23. Progress notes dated 02/09/23 and 02/14/23 indicated the medications were not available. Resident #28 A review of Resident #28's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: peripheral vascular disease, high blood pressure, schizophrenia, insomnia, and muscle pain. A review of Resident #28's physician orders dated 02/15/23 indicated the resident had orders for cyclobenzaprine (muscle relaxant) 5 mg three times a day, Cymbalta (for depression) 20 mg. in the morning every other day, Latuda (for schizophrenia) 80 mg one time a day A review of Resident #28's MAR dated 01/01/23 through 01/31/23, indicated she did not receive Latuda on 01/03/23 and 01/03/23, did not receive Cymbalta on 01/11/23, and did not receive cyclobenzaprine on 01/30/23 and 01/31/23. Progress notes dated 01/03/23, 01/05/23, 01/11/23, 01/30/23 and 01/31/23 indicated the medications were not available. A review of Resident #28's MAR dated 02/01/23 through 02/28/23, indicated she did not receive cyclobenzaprine on 02/01/23, 02/02/23, and 02/03/23. Progress notes dated 02/01/23, 02/02/23 and 02/0323 indicated the medication was not available. Resident #29 A review of Resident #29's clinical record indicated the resident was admitted to the facility on [DATE] with the following diagnoses: diabetes, multiple sclerosis (disease affecting the central nervous system causing muscle stiffness or spasms, paralysis typically in the legs), pressure ulcers (wounds that occur when the skin and tissue are damaged by prolonged pressure), high blood pressure, venous thrombosis and embolism (blood clot in a blood vessel), muscle wasting and atrophy (loss of muscle tissue). A review of Resident #29's physician orders dated 02/15/23 indicated the resident had orders for Alendronate Sodium (heart burn) 70 mg, one time in the morning every 7 days; Arginaid Packet (nutritional supplement for wound healing) 1 packet, two times a day; Baclofen (muscle spasms) 10 mg, four times a day; Metformin (diabetes) 500mg, two times a day; Rivaroxaban (anticoagulant used to prevent blood clots) 20 mg, one time a day, and Simvastatin (cholesterol) 10 mg, one time a day at bedtime. A review of Resident #29's MAR dated 01/01/23 through 01/31/23, indicated he did not receive the following medications: Alendronate Sodium (heart burn) on 01/05, 01/13; Arginaid Packet (nutritional supplement for wound healing) one dose on 01/02, 01/09, 01/10, 01/11, 01/12, 01/12 and 01/30; Baclofen (muscle spasms) four doses on 01/09, 01/25 and one dose on 01/24; Metformin (diabetes) one dose on 01/09 and two doses on 01/24; Rivaroxaban (anticoagulant used to prevent blood clots) on 01/09 01/10, 01/11, 01/12, 01/23, 01/24, 01/25 and 01/26. Progress notes dated 01/02, 01/06, 01/09, 01/10, 01/11, 01/,12, 01/13, 01/23, 01/24, 01/25, 01/26, and 01/30 indicated the medications were not available. A review of Resident #29's MAR dated 02/01/23 through 02/28/23, indicated he did not receive the following medications: Alendronate Sodium (heart burn) on 02/03; Baclofen (muscle spasms) two doses on 02/09; Metformin (diabetes) one dose on 02/07 and two doses on 02/08; Rivaroxaban (anticoagulant used to prevent blood clots) on 02/03; Simvastatin (cholesterol) on 02/06. Progress notes dated 02/03, 02/06, 02/07, 02/08, and 02/09 indicated the medications were not available. Resident #31 A review of Resident #31's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: diabetes, pain, high blood pressure, and depression. A review of Resident #31's physician orders dated 02/15/23 indicated the resident had orders for metformin (for blood sugar) 500 mg. twice a day, trazadone (for depression or sleep) 50 mg. 0,5 tablet one time a day. A review of Resident #31's MAR dated 02/01/23 through 02/28/23, indicated she did not receive the metformin (for blood sugar) 500 mg. morning dose on 02/03/23 and did not receive trazadone on 02/09/23. Progress notes dated 02/03/23 and 02/08/23 indicated the medications were not available. Resident #38 A review of Resident #38's clinical record indicated the resident was admitted to the facility on [DATE] with the following diagnoses: nontraumatic intracerebral hemorrhage (bleeding inside the brain from a ruptured blood vessel that may cause severe headache, tingling, or paralysis in face, arm, or leg, trouble swallowing), dysphagia (difficulty in swallowing), muscle weakness, coronary artery disease (narrowing of major blood vessels supplying blood to the heart that may cause chest pain and shortness of breath), high blood pressure, ischemic cardiomyopathy (weak heart muscles due to heart attack or coronary heart disease that may cause fatigue and shortness of breath), systolic and diastolic congestive heart failure (the heart cannot effectively contract with each heartbeat and relax in between), hemiplegia and hemiparesis following cerebral infarction affecting right side (right sided weakness and paralysis caused by a lack of blood and oxygen supply to the brain). A review of Resident #38's physician orders dated 02/15/23 indicated the resident had orders for Lisinopril (blood pressure) 20 mg, one time a day and Baclofen (muscle spasms) 10 mg, three times a day. A review of Resident #38's MAR dated 01/01/23 through 01/31/23, indicated he did not receive Baclofen (muscle spasms) one doses on 01/02. Progress notes dated 01/02 indicated the medication was not available. A review of Resident #38's MAR dated 02/01/23 through 02/28/23, indicated he did not receive Lisinopril on 02/03 and 02/07. Progress notes dated 02/03 and 02/07 indicated the medications were not available. Resident #248 A review of Resident # 248's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: partial intestine obstruction, low thyroid function, diabetes, Parkinson's (nerve cell damage of the brain), high blood pressure, congestive heart failure, arthritis, and chronic kidney disease. A review of Resident # 248's physician orders dated 02/07/23 indicated the resident had orders for Amlodipine 10 mg daily, Donepezil HCl 10 mg daily, Fluticasone Nasal Spray daily, Pantoprazole 40 mg daily, Vitamin C daily, Bumetanide 1 mg 2 (two) times a day, Carbidopa-Levodopa ER (extended release) 50-200 mg 3(three) times a day, Metoprolol tartrate 12.5 mg 2(two) times a day, Mucinex DM Extended Release 12 Hour 30-600 mg 2 (two) times a day for 10 days, Gabapentin 300mg 3(three) times a day, Primidone 50 mg 3(three) times a day, and Trihexyphenidyl 2 mg 3 (three) times a day. A review of Resident # 248's MAR dated 02/01/2023 through 02/28/2023 indicated she did not receive these medications on the following dates: *Amlodipine (blood pressure) on 02/08/23, *Donepezil (dementia) on 02/07/23 and 02/08/23, *Fluticasone Nasal Spray (allergies) on 02/08/23, *Pantoprazole (stomach reflux) on 02/08/23, *Vitamin C (supplement) on 02/08/2023, *Bumetanide: (diuretic for congestive heart failure) 1 dose on 02/07/23, 2 doses on 02/08/23, 1 dose on 02/09/23, and 2 doses on 02/10/23 (total 6 doses) *Carbidopa-Levodopa (Parkinson's disease) 1 dose on 02/07/23, 2 doses on 02/08/23 and 1 dose on 02/10/2023 (total 4 doses) *Metoprolol tartrate(blood pressure) 2 doses on 02/08/23, *Mucinex DM (cough)on 02/08/23, *Gabapentin (seizures) 3 doses on 02/08/23 and 1 dose on 02/10/23 (total 4 doses) *Primidone (seizures) 2 doses on 02/07/23, 2 doses on 02/08/23 and 1 dose on 02/10/23 (total 5 doses), and *Trihexyphenidyl (Parkinson's disease) 2 doses on 02/08/23 and 1 dose on 02/10/23. A review of Resident #248's progress notes dated 02/08/23, 02/09, and 02/10/2023 indicated the medications were not available. Further review of the progress notes dated 02/08/23 through 02/11/2023 indicated neither the physician nor DON were notified of medications not being administered. Resident #249 A review of Resident #249's clinical records indicated the resident was admitted on [DATE] with diagnoses including: panic disorder, hypertension, hyperlipidemia, cerebral vascular accident (stroke), and chronic obstructive pulmonary disease. A review of Resident 249's physician orders dated 02/02/23 indicated the resident had orders for amlodipine 5mg daily, atorvastatin 20 mg daily, Climara Transdermal Patch 0.05 mg weekly, docusate sodium 100 mg two (2) times a day, donepezil 10 mg daily, duloxetine 30 mg daily, flaxseed oil 1000 mg daily, Flonase Allergy Relief Nasal Spray daily, meloxicam 7.5 mg daily, and polyethylene glycol powder 17 grams daily. A review of Resident # 249's MAR dated 02/01/2023 through 02/28/2023 indicated she did not receive these medications on the following dates: *Amlodipine (blood pressure) on 02/02/23 and 02/6/2023, *Atorvastatin (cholesterol) on 02/03/23 and 02/04/23, *Climara Transdermal patch (hormone) on 02/03/23 and 02/10/23, *Docusate sodium (stool softener) on 02/03/2023, *Donepezil (dementia)on 02/02/23, 02/04/23, and 02/05/23 *Duloxetine (anxiety, depression) 02/03/23, *Flaxseed oil (cholesterol) on 02/03/23 through 02/15/2023 (13 days), *Flonase Allergy Spray (allergies) on 02/03/23, 02/06/23, and 02/07/23, *Meloxicam (pain)02/03/2023, and *Polyethylene powder (laxative) on 02/03/23. A review of Resident #249's progress notes dated from 02/03/23 through 02/15/23 indicated medications were not available. Progress notes dated 02/03/23 and 02/04/23 indicated the charge nurse was made aware of some un-named medications not being available. No documentation was found to indicate the physician or DON were made aware of the medications being unavailable. Resident #251 A review of Resident #251's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses including: colon cancer, benign prostatic hyperplasia (enlarged prostate), elevated prostate specific antigen, and peripheral vascular disease. A review of Resident #251's physician orders dated 02/03/23 indicated the resident had an order for Tamsulosin HCL oral capsule 0.4 mg every day. A review of Resident # 251's MAR dated 02/01/23 through 02/28/23 indicated he did not receive Tamsulosin (enlarged prostate) on 02/08/23. A review of Resident #251's progress note dated 02/08/23 indicated Tamsulosin was not available. No documentation was found to indicate the physician, or the DON were notified. During an interview on 02/15/23 at 09:40 AM, LVN A stated that if a medication was not available, she would go to the medication room and see if it was available in the e-Safe (a pharmacy provided safe stocked with emergency and/or frequently ordered medications). She said if she could not get it from the safe, then she would call the pharmacy and if she could not get it in a timely manner, she said she would request the pharmacy to get it from a local pharmacy. During an interview on 02/15/23 at 09:53, MA C said if she did not have a medication available, she would tell the charge nurse. She said the charge nurse would check the e-Safe in the medication room and if not there, then the nurse would call the pharmacy. MA C also said that she re-ordered medications on Monday, Wednesday, and Friday for meds scheduled to be administered on the 6 -2 (Day) shift. She said the medication aide on the 2-10 (Evening) shift ordered medications for that shift. She also said the medication aide that worked on the weekends would re-order any medications if needed. During an interview on 02/15/23 at 10:01 AM, LVN B said if she needed a medication, she would attempt to get it from the e-Safe and if she could not, she would call the pharmacy. During an interview on 02/15/23 at 02:20 PM, MA D said she would tell the charge nurse if she did not have a needed medication in her cart. She said the nurses try to get it from the e-Safe first and if they can't, then they call the pharmacy. During an interview on 02/15/23 at 02:30 PM, the DON said she reviewed the orders for new admissions and checked the cart to ensure medications are available as ordered. She said she expected the medication aides to monitor for needed medications. An In-Service Report dated 01/13/2023 and signed by nurses and medication aides, contained the following instructions: If the medication is not available in the e-kit, the doctor needs to be notified. An in-service dated 01/24/2023 instructed the nurses and medications aides to request the Provider's pharmacy to obtain needed medications from a local pharmacy if the Provider's pharmacy could not deliver within 24 hours. The in-service also instructed the nurses and med aides to notify the DON/ADON if they had problems getting meds delivered. A review of the facility's policy PA 03-2.03 Ordering Medications provides the following information: Medications and related products are received from the pharmacy supplier on a timely basis. Section 3 under Procedures provides the following directions: If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery. Use the emergency kit when the resident needs a medication prior to pharmacy delivery. If not in the emergency kit, contact the pharmacy for possible local pharmacy to fill enough of the medication until the next scheduled delivery. 37495 42190 47204

Based on observation, interview, and record review the facility failed to post Nursing Staffing Data information daily as required for 3 of 15 days (02/11/23, 02/12/23 and 02/14/23) reviewed for February 2023 nursing staffing. The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides or the daily census for February 11th , 12th , and 14th of 2023. This failure could cause residents, families, and visitors to be unaware of the facility daily staffing requirements. Findings included: During an observation on 02/13/23 at 8:45 a.m., the staffing sheet posted was dated 02/10/23. During an observation on 02/13/23 at 11:05 a.m., the staffing sheet posted was dated 02/13/23. During an observation on 02/14/23 at 9:53 a.m., the staffing sheet posted was dated 02/13/23. During an observation on 02/14/23 at 3:01 p.m., the staffing sheet posted was dated 02/13/23. During an observation on 02/15/23 at 8:04 a.m., the staffing sheet posted was dated 02/13/23. During an interview on 02/15/23 at 8:29 a.m., the ADM said she expected the staffing to be posted daily so residents and family members could be assured adequate staffing was being provided. The ADM said she thought the DON was responsible for ensuring the staffing was posted daily but did not know for sure. During an observation and interview on 02/15/23 at 8:38 a.m., the DON said she expected the staffing to be posted daily so residents and family members could be assured adequate staffing was being provided. The DON said during the week the ADON was responsible for posting the staffing sheet daily and the RN supervisor was responsible for posting it on the weekend. The DON said she posted the staffing sheet on 02/13/23 and the one she replaced was dated 02/10/23. The DON said they did not have staffing sheets for 02/11/23 and 02/12/23. The DON said she was not sure why the staffing sheets were not post over the weekend and would in-service the RN supervisor before her next weekend shift. The DON observed the staffing sheet posted and said it was dated 02/13/23. The DON said the ADON worked on the floor as a CNA on 02/14/23 and was unable to post the staffing sheet. The DON said she was responsible for posting the staffing sheet if the ADON was unable to do so. The DON said she got busy and forgot to post the staffing sheet on 02/14/23. The DON said she would post an updated staffing sheet for today. During an observation on 02/15/23 at 9:44 a.m., the staffing sheet posted was dated 02/15/23. A record review of the facility's staffing sheets for February 2023 indicated there were no documented staffing sheets on 02/11/23, 02/12/23 and 02/14/23.

Based on interview and record review, the facility failed to ensure all staff received dementia management training for 2 of 6 Certified Nurse Aide (CNAs) reviewed for required dementia management annual training (CNA C, and CNA D). The facility did not ensure CNA C, and CNA D completed the required dementia management training as part of their annual training. This failure could place the residents with dementia at risk of a poor quality of care by staff with inadequate training. Findings included: Record review of the personal files for the following employees indicated the employees had not completed dementia management as part of their annual training: *CNA Cl - hire date 4-29-20- no annual trainings on Dementia Management; and *CNA D - hire date 8/31/20 - - no annual trainings on Dementia Management. During an interview on 12/15/21 at 2:42pm the DON said they did not have a local Human Resource (HR) manager onsite, and their HR was off sight at their corporate office. She said the HR corporate office was the one responsible for assigning all trainings. She said the HR corporate office sent her email notification on what trainings were due for each staff. DON reviewed completion reports and verified Dementia Management training had not been completed yet.

Based on interview and record review, the facility failed to ensure a therapeutic diet was provided in accordance with the written plan of care for 2 of 17 residents reviewed for nutrition. (Resident #s 7 & 30) The facility failed to ensure Resident #s 7 and 30 received health shakes with all meals as ordered by the physician. This failure could place residents at risk for not receiving appropriate treatment and services to meet their needs. Findings included: 1. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, and order for Health Shakes with all meals effective 9/18/20. During an observation of lunch meal on 12/14/21 at 12:58 pm Resident #7 did not receive a healthshake with lunch meal as ordered. Record review of a revised care plan dated 12/13/21 indicated Resident #7 had potential nutritional problem due to diet restrictions. Interventions: provide, serve diet as ordered. Observe intake and record every meal. Record review of a nutrition RD assessment dated [DATE] indicated was to receive a healthshake three times a day (DC order pending). 2. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of lunch meals on 12/13/21 at 12:10pm Resident #30 did not receive a healthshake with lunch meals as ordered. During an observation of lunch meal on 12/14/21 at 12:54pm Resident #30 did not receive a healthshake with lunch meals as ordered. Record review of a revised care plan dated 12/13/21 indicated Resident #30 was anemic. Intervention: Review diet and make recommendations as required. Care plan did not address healthshake. Record review of a nutrition assessment dated [DATE] indicated Resident #30 had no nutritional diagnosis. Diet: was on a mechanical soft diet. Supplements: was to have healthshakes three times a day and House 2.0 60 cc three times a day. Record review of an undated diet report printed on 12/13/21 indicated Resident #7 and Resident #30 were to each receive a health shake with all meals During an interview on 12/15/21 at 1:40 p.m., with DON and ADON they said they notified the DM on diet changes using communication forms; did not make a copy for chart. They said a nurse checks the meal tickets for each meal. DON said if Residents #7 and 30 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was not aware Resident #s 7 and 30 was not getting a health shake with every meal. During an interview on 12/15/21 at 1:44pm the Dietary manager said the staff gives her a communication note for each resident's diet and diet changes and then she files it away the communication note in her office. DM said she currently had 16 residents who received health shakes with meal, DM provided a had written list with the names of the 16 residents and Resident #s 7 and 30 names were not on the handwritten list of residents who received health shakes. DM said she had never received a communication note regarding receiving health shake with all meals for Resident #7 or #30 and was not aware either residents were supposed to receive health shakes. DM said for the 16 residents that she was aware of to have health shakes the kitchen put the shakes on the resident's meal trays.

Citation Text for Tag 0659, Regulation FF11 [NAME], [NAME] Based on interview and record review the facility failed to ensure the written plan of care was implemented for 1 of 2 residents (Resident #1) reviewed for wound care. The facility did not ensure that Resident #1's dressing changes/wound care to pressure areas were done as ordered by the physician. This failure could place residents at risk for infection, and decline in condition. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS dated [DATE] indicated that Resident #1's cognition was intact and required supervision with activities of daily living . The most recent MDS dated [DATE] indicated that Resident #1 had 1 stage 4 pressure ulcer that was present upon admission, and 2 unstageable pressure injuries that were present upon admission. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan revised 3/31/2021 indicated that Resident #1 had pressure ulcers. Interventions included administering treatments as ordered and follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A treatment Administration Record for Resident #1 indicated the following: There was no documentation indicating that wound care to left and right heels and sacral/coccyx was administered on the following days: Friday 3/26, 4/9 Saturday 3/6, 3/13. 3/20, 3/27, 4/3, 4/10, Sunday 3/7 3/14, 3/21, 3/28 , 4/4, 4/11 During an interview on 4/15/2021 at 11:00 a.m. DON said the charge nurse is responsible for wound care on the weekends, and information should be charted on the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/15/2021 at 12:55 p.m. LVN A said she had worked in the facility for [AGE] years and had been wound care certified for [AGE] years. LVN A said she worked Monday-Fridays, but recently had been taking some Fridays off. LVN said the charge nurse was in responsible for wound care when she was off. Said she documents treatment/dressing changes on the treatment administration record only. During an interview on 4/15/2021 2:06 p.m. LVN B said charge nurses do wound care on the weekends, and it is documented on the treatment administration records. A Clean Dressing Change Policy dated December 2009 indicated that documentation of treatment was to be entered on the Treatment Administration Record .

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the minimum healthcare information necessary to properly care for a resident for 5 of 5 residents reviewed for baseline care plans. (Resident #s 1, 2, 3, 4, and 5) -Resident #s 1, 2, 3, 4, and 5 did not have goals and interventions for transmission-based precautions or for [DIAGNOSES REDACTED]. -Resident #4 did not have goals and interventions for his falls or surgical wounds. -Resident #5 did not have goals and interventions for his falls. These failures could place newly admitted residents at risk for not receiving care and services to meet their needs. Findings included: 1. An Admission Record dated 01/29/21 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. A physician order [REDACTED].#1 had an order indicating she was to receive services for the management of COVID-19. A baseline care plan dated 01/21/21 for Resident #1 did not address COVID-19. An Admission Record dated 01/29/21 indicated Resident #2 was a [AGE] year-old female admitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. Physician orders [REDACTED].#2 had a [DIAGNOSES REDACTED]. A baseline care plan dated 01/21/21 for Resident #2 did not address COVID-19. An Admission Record dated 01/29/21 indicated Resident #3 was an [AGE] year-old male admitted on [DATE]. His admitting [DIAGNOSES REDACTED]. Physician orders [REDACTED].#3 had a [DIAGNOSES REDACTED]. A baseline care plan dated 01/18/21 for Resident #3 did not address COVID-19. An Admission Record dated 01/29/21 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His admitting [DIAGNOSES REDACTED]. Physician orders [REDACTED].#4 had a [DIAGNOSES REDACTED]. A baseline care plan dated 01/07/21 for Resident #4 did not address COVID-19. An Admission Record dated 01/29/21 indicated Resident #5 was a [AGE] year-old male admitted on [DATE]. His admitting [DIAGNOSES REDACTED]. Physician orders [REDACTED].#5 had a [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] for Resident #5 did not reflect the [DIAGNOSES REDACTED]. A baseline care plan dated 01/07/21 for Resident #5 did not address COVID-19. During an interview on 01/29/21 at 03:48 p.m., the DON said she did not realize the baseline care plan program in their EMR was not updated to include COVID-19. 2. An Admission Record dated 01/29/21 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. He had [DIAGNOSES REDACTED]. A Skin-Head to Toe Skin Check assessment dated [DATE] from the facility he admitted from indicated Resident #4 had a surgical incision to the left inner ankle and left outer ankle, pressure injury to the left heel and to p of right foot, arterial ulcer to the right great toe and right 2nd toe, and fracture blisters to the left inner ankle and top of the left foot. A History and Physical dated 12/04/20 from the facility he admitted from indicated Resident #4 had a fall causing the fracture to his ankle. An Admission Data Collection form dated 01/05/21 indicated Resident #4 had no pressure injuries, had non-pressure areas/other skin conditions, and it was a blister on the left foot. A baseline care plan dated 01/07/21 for Resident #4 indicated he was at risk for falls and had surgical wounds. The baseline care plan did not have goals and interventions for his falls or surgical wounds. It was marked indicating RN review. 3. An Admission Record dated 01/29/21 indicated Resident #5 was a [AGE] year-old male admitted on [DATE]. Physician orders [REDACTED].#5 had [DIAGNOSES REDACTED]. A baseline care plan dated 01/07/21 for Resident #5 indicated he was at risk for falls. The baseline care plan did not have goals and interventions for his falls or surgical wounds. It was marked indicating RN review. During an interview on 01/29/21 at 03:48 p.m., the DON said she reviewed the baseline care plans. She said information for the baseline care plan was obtained from the clinical record-transfer forms, physician orders, admission assessments, and skin assessments She said the goals and interventions were to be completed on the baseline care plan. She said she just missed it on Resident #s 4 and 5.

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development and worsening of pressure injuries for 2 of 2 residents reviewed for pressure injuries. (Resident #s 1 and 2) 1. The facility did not accurately assess the resident ' s skin and identify he had TED hose on until 5 days after his admission. Resident #1 was admitted without pressure injuries and with TED hose (compression stockings) from the hospital. The resident developed five facility acquired pressure injuries on his left lower extremity and six facility acquired pressure injuries on his right lower extremity. 2. The facility did not accurately assess the Resident #2's pressure injuries upon admission. The failure could place 9 dependent residents at risk for developing pressure injuries and a decline in existing pressure injuries. Findings included: A face sheet dated 10/03/16 indicated Resident #1 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. A hospital Assessment Report dated 9/20/16 at 8:50 a.m. documented Resident #1 had TED hose on. The Nursing Admission Data Collection assessment dated [DATE], day of hospital discharge, at 8:15 p.m. indicated Resident #1 did not have skin issues upon admission from the hospital. The assessment did not address TED hose. The Documentation Survey Report dated September 2016 indicated Resident #1 required limited assistance with dressing on 6 a.m. until 2 p.m. shift and 2 p.m. until 10 p.m. shift on Wednesday 9/21/16. The resident required extensive assistance on 2 p.m. until 10 p.m. shift on Saturday 9/24/16. During an interview on 10/03/16 at 8:41 a.m., the administrator said he was called on Sunday 9/25/16 and was notified Resident #1 had TED hose removed and had wounds to his lower extremities. The administrator said he initiated an investigation. He said he spoke to Resident #1 ' s wife on Monday 9/26/16 and he was made aware that Resident #1 had not had a shower since he was admitted (9/20). He indicated agency staff was utilized for treatment rounds due to regular treatment nurse, LVN D, was on vacation when Resident #1 and #2 were admitted . A Provider Investigation Report dated 9/25/16 indicated time reported was at 10:12 p.m. and indicated a CNA found an area of altered skin integrity and reported it to the charge nurse. The description of allegation was reported as lack of assessment, monitoring and treatment that resulted in potentially facility acquired altered skin for resident, family was concerned Resident #1 had not been showered since he admitted on [DATE]. The provider response was suspended LVNs C and H, notified family, physician and regional team, and investigation. The investigation summary stated resident did not receive a shower for four days. The hospital documented resident received TED hose while he was hospitalized and family stated he had them on before he discharged . The East Shower List dated Saturday 9/24/16 listed Resident #1 on the 6 a.m. until 2 p.m. shower schedule on Tuesdays, Thursdays and Saturdays, but no shower was documented until Tuesday 9/27/16. During an interview on 10/3/16 at 11:01 a.m., LVN C said she performed a head to toe assessment of Resident #1 within a couple of hours after admission and said he was not wearing TED hose and had no skin issues. She said she was off for several days and he had wounds when she returned to work. She indicated she attended in-services on assessment system. She said it was the admitting nurse ' s responsibility to do an initial head to toe assessment and if there was a skin issue, the treatment nurse was notified. During an interview on 10/3/16 at 2:25 p.m., LVN H said Resident #1 admitted at the end of her shift on 9/20/16 and LVN C did the initial assessment. She said she did not personally assess Resident #1 until 9/21/16. She said she recalled he stood up to use the urinal and did not have TED hose on. She said she did not observe wounds. During an interview on 10/3/16 at 1:02 p.m., LVN F said she recalled she assessed Resident #1 ' s lower extremities and he did not have on TED hose and he had no skin issues. She said she worked the 10 p.m. until 6 a.m. shift on the night Resident #1 was admitted . A nursing note dated 9/25/16 indicated Resident #1 had TED hose on his legs. The note indicated there was no physician's order [REDACTED]. The nursing note said Resident #1 ' s physician and the DON were notified. A care plan dated 9/26/16 indicated Resident #1 had the following pressure injuries: #1-DTI on top of his left foot, #2- Stage 3 on his left inner ankle, #3-DTI on his left outer lateral plantar #4- Stage 1 to upper right foot , #5-Stage 1 on mid right top of his foot #6-DTI on his right medial dorsal calf #7-DTI on his right lateral dorsal calf, #8-DTI on his left top/medial plantar #9-Stage 2 on lower tope of right foot #10 and #11-two Stage 1s below right dorsal knee. The goal was to have ulcers to show signs of healing and remain free from infection. The interventions included: to follow facility policies and procedures, administer treatments as ordered and observe for effectiveness, and provide weekly treatment documentation and measurement of skin breakdown. A Braden score dated 9/26/16 indicated Resident #1 had a score of 16 which was at risk for developing pressure injuries. (A score of 12 or less represents high risk) The Clinical Physician order [REDACTED].#1 ' s pressure injuries: Pressure Injury #1- apply skin prep to unstageable area to the left top of his left foot every shift and as needed until healed. Pressure Injury #2 - cleanse stage 3 area to left inner ankle with wound cleanser/normal saline, pat dry, prep surrounding skin, apply Venelex ointment (promotes wound healing, debridement) and a clean, dry dressing daily until healed. Pressure Injury #3 - apply skin prep to unstageable area to left plantar (outer/lateral) every shift and as needed until healed. Pressure Injury #4 - apply Venelex ointment to stage 1 area to his upper right foot every day and leave open to air until healed. Pressure Injury #5 - apply Venelex ointment to stage 1 area to his right top of foot (mid) every day and leave open to air until healed. Pressure Injury #6 - apply skin prep to unstageable area to his right dorsal calf (med) every shift and as needed until healed. Pressure Injury #7 - apply skin prep to unstageable to his right dorsal calf (lateral) every shift and as needed until healed. The Clinical Physician order [REDACTED]. The orders indicated wound care orders to do a head to toe assessment every week on Monday and to monitor pressure area every day for signs and symptoms of infection, increased drainage, increased pain, odor, report any decline or change to physician/responsible party-ensure dressing is clean, dry and intact. An MDS dated [DATE] indicated Resident #1 was understood and he usually understood others. He required extensive assist for bed mobility, dressing, transfers, toileting and bathing. He required limited assistance with eating. Resident #1 was occasionally incontinent of bowel and bladder and at risk for pressure injury development. The MDS reflected four stage 1 pressure injuries, two stage 2 pressure injuries, one stage 3 pressure injury, and five deep tissue injuries, all were coded as not present upon admission. During an observation and interview on 10/03/16 at 2:15 p.m., Resident #1 had the following pressure injuries measured by LVN D: Pressure Injury #1 - unstageable possible DTI blister to the top of his left foot 3.2 cm x 4.8 cm Pressure Injury #2 - stage 3 pressure injury to his left inner ankle 0.9 cm x 0.6 cm with serosaguinous drainage Pressure Injury #3 - unstageable to his left outer foot measured 0.9 cm x 4.8 cm Pressure Injuriy #4 - stage 1 on top of his right foot measured 0.5 cm x 0.6 cm Pressure Injury #5 - stage 1 on top of his right foot, measured 0.5 cm x 0.3 cm Pressure Injury #6 -scabbed area measured 0.4 cm x 9.2 cm wound on his right outer under knee area (not staged by LVN D) Pressure Injury #7 - wound measured 0.5 cm x 3.5 cm wound to his right inner knee (not staged by LVN D) Pressure Injury #8 - stage 1 on top of his right foot measured 0.5 cm x 0.3 cm Pressure Injury #9 - unstageable scab to his left inner foot 0.9 cm x 8 cm (not staged by LVN D) Pressure Injury #10 - wound measured 0.1cm x 0.6 cm area on back of his right knee (not staged by LVN D) Pressure Injury # 11 was a wound that was healed under his left inner knee. During an interview on 10/03/16 at 2:15 p.m., LVN D said Resident #1 ' s wounds were from TED hose not being taken off until the fifth day after admission from hospital. She indicated she was on vacation when Resident #1 admitted and she first assessed his wounds on Monday 9/26/16. Resident #1 said he did not remember how he got his wounds and said he did not recall if he wore TED hose. The Clinical Physician order [REDACTED].#1) with wound cleanser/normal saline, pat dry, prep surrounding tissue, apply Venelex to open area and a clean, dry dressing daily until healed. No other wound care orders were changed. An ultrasound report dated 10/03/16 indicated Resident #1 had severe [MEDICAL CONDITION] in the left lower extremity. During an interview on 10/3/16 at 2:31 p.m., CNA I said Resident #1 was independent with ADLs and asked for assistance as needed. She denied she assisted him with anshower and did not remember if he had TED hose on. During an interview on 10/3/16 at 2:36 p.m., CNA J said Resident #1 required two staff assistance and was incontinent. She said she pushed him in his wheelchair back from smoke breaks because he tired easily. She did not recall if he had TED hose on. During an interview on 10/4/16 at 2:20 p.m., CNA P said Resident #1 was independent with ADLs and only required his tray brought to him. During an observation on 10/4/16 at 2:53 p.m., LVN D provided incontinent care after Resident #1 was incontinent of bowel. There was no skin issues identified to perineal area or groin. During an interview on 10/3/16 at 3:41 p.m., LVN K said she first cared for Resident #1 on 9/25/16 and did not recall he wore TED hose. She said he required one staff person with assistance to transfer and was continent. She said the charge nurse was responsible for head to toe assessment upon admission and LVN D was notified if a resident had any skin issues. 2. A face sheet dated 10/3/16 indicated Resident #2 was [AGE] years old, admitted [DATE], and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #2 had a cognitive pattern score of 14 out of 15, indicated a high recall capacity. Her functional status was coded extensive assistance was required for bed mobility, dressing and personal hygiene and dependent for transfers and toileting. Her MDS indicated she had six stage 3 pressure injuries present upon original admission. The admission care plan dated 7/27/16 indicated Resident #2 required assistance of two staff for bathing, dressing, and toileting. The care plan indicated the resident required to be repositioned frequently and a weekly skin audit to prevent /heal skin breakdown/pressure injuries. A readmission skin assessment dated [DATE] indicated Resident #2 had the following skin issues identified as documented by RN R (agency nurse): Skin tear #1 -2 cm x 1 cm x 0.2 cm to her right knee (rear) Skin tear #2 -0.5 cm x 0.5 cm x 0.1 cm to her right knee (rear) Skin tear #3 -6.5 cm x 6 cm x 0.2 cm to her left buttock Skin tear #4 -2 cm x 0.5 cm x 0.2 cm to her right thigh (rear) Pressure Injury - wound measured 26 cm x 21 cm 8 cm to her sacrum Pressure Injury -wound measured 5.5 cm x 3.5 cm x 0.1 cm to her right heel noted as [MEDICATION NAME] and is no longer open A Braden scale dated 10/2/16 indicated Resident #2's score was 12 which indicated she was at high risk for pressure injuries. During an observation and interview on 10/03/16 at 5:02 p.m., LVN D said the agency RN who originally assessed the pressure injuries of Resident #2 was incorrect in her assessment. Resident #2 had the following pressure injuries measured and described by LVN D: Pressure Injury #1 - stage 4 presents as a stage 3, had slough at base 15 cm x 9.1 cm x 0.9 cm pale red wound bed with thin coating and moderate serosanguinous drainage and small area of thin yellow slough at base on her right inner buttock/coccyx area Pressure Injury #2 -stage 2 measured 4.1cm x 2.4 cm with red glossy wound bed on her left upper buttock Pressure Injury #3 -stage 2 measured 1.7 cm x 0.6 cm with red glossy wound bed and jagged edges and serosanguinous drainage to her left lower buttock Pressure Injury #4 -stage 2 measured 0.5 cm x 0.8 cm with pale pink glossy wound bed with scant serosanguinous drainage to her left gluteal fold Pressure Injury #5- stage 2 measured 1.7 cm x 0.5 cm with a red glossy wound bed with small amount of serosanguinous drainage to her right upper buttock Pressure Injury #6 -stage 2 measured 2 cm x 2.4 cm with pale pink wound bed with rounded borders on her right medial buttock Pressure Injury #7 -stage 2 measured 0.7 cm x 0.4 cm with a glossy red wound bed with scant serosanguinous drainage to her right lower buttock Pressure Injury #8 -stage 2 measured 1.8 cm x 7 cm with a red glossy wound bed with scant serosanguinous drainage to her right outer gluteal fold Pressure Injury #9 -stage 2 measured 1.1 cm x 2 cm with a pale pink and red wound bed with a slightly raised border on her right medial gluteal fold Pressure Injury #10 -stage 2 measured 0.5 cm x 0.4 cm with a pale pink wound bed to her right lower gluteal fold Pressure Injury #11 -stage 2 measured 1.3 cm x 0.6 cm with a glossy dry red wound bed on her right outer thigh Pressure Injury #12 - DTI measured 1 cm x 9.8 cm on her right ischial area Pressure Injury #13 -stage 2 measured 0.7 cm x 0.9 with a pale red wound bed to her right outer buttock Pressure Injury #14 -stage 2 measured 1.3 cm x 2.4 cm with a pale glossy red wound bed to her right outer buttock below pressure injury #14 Pressure Injury #15 -unstageable STDI measured 1.4 cm x 1.4 cm on her right lateral buttock/coccyx area Pressure Injury #16 -unstageable SDTI measured 1.4 cm x 1 cm on her right lateral buttock/coccyx area A Skin Management Policy and Procedure dated March 2008 indicated for assessments (1) Upon Admission, all residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale (2) Residents admitted with skin impairments will have: (a) appropriate interventions implemented to promote healing, (b) a physician's order [REDACTED]. The CMS 672 dated 10/3/16 indicated there were 9 dependent residents.

Based on observation, interview, and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 3 of 5 residents reviewed for neglect and supervision. (Resident #s 1, 2, 3, and 4) The facility did not implement interventions to prevent Residents #1,#3, and #4 from attacking others. These 3 residents exhibited patterns of aggressive behaviors toward other residents and the staff. All 3 of these residents were fighting without staff in the immediate area. After surveyor intervention, the administrator stopped the altercation and placed all three on 1:1 supervision. Later that day, Resident #1 punched and choked LVN B. The facility did not prevent Resident #1 from attacking Resident #2, and placing him in a choke hold. An Immediate Jeopardy situation was identified on 07/26/16. The Immediate Jeopardy was removed on 07/27/16. The facility remained out of compliance at a pattern of potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 20 residents on the secure unit at risk of severe injuries. Findings included: The Abuse and Neglect Prohibition Policy dated 06/13 indicated each resident has the right to be free from neglect. 1. Physician orders [REDACTED].#1 was [AGE] years old, was admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was severely cognitively impaired and had physical behaviors directed towards others four to six times a week. The Care Plan dated 07/01/16 indicated Resident #1 had behaviors of physical aggression, being combative, and agitation. The interventions listed included: re-direct as needed, assist resident with coping mechanisms, allow choices, anticipate needs, administer medications as ordered, and analyze triggers. An Incident Report dated 06/26/16 indicated at 2:30 p.m., Resident #1 attacked CNA A from behind, placed his arm around her neck, and pushed her to the floor. During an interview on 07/26/16 at 1:53 p.m., CNA A said she was in the shower bathing another resident. She said Resident #1 came into the shower room, came up behind her, wrapped his arm around her neck, and put her in a tight choke hold. She said the pressure the resident was applying to her neck was painful. She said the resident took her to the floor. She said she was unable to notify other staff, and no staff came to help her. She said another resident in the room who she had been bathing came to help her. CNA A said she could finally get up and get other staff for help. She said her throat and neck hurt for several days. She said Resident #1 was aggressive and she felt he needed one-on-one supervision. A nursing note dated 06/26/16 indicated at 2:39 p.m. (following the shower incident), Resident #1 was placed on 15 minute checks. A nursing note dated 06/30/16 at 10:35 a.m., indicated Resident #1 would be taken off of 15 minute checks at 2:00 p.m. that day. A nursing note dated 07/02/16 indicated at 4:27 p.m., Resident #1 was combative with staff. The resident was in a female's room and attempted to attack staff when they tried to remove him. A nursing note dated 07/08/16 indicated at 1:21 a.m., Resident #1 was combative with staff, very agitated, and tried to hit staff when re-directed. An Incident Report dated 07/14/16 indicated at 10:00 a.m., Resident #1 attacked Resident #2. LVN B heard residents yelling and went to Resident #2's room. She found Resident #1 had Resident #2 in a choke hold and was hitting him. LVN B separated the residents. The incident report indicated Resident #1 was aggressive at times and he was placed on 15 minute checks. A nursing note dated 07/17/16 at 2:05 p.m., was the last mention of Resident #1 being on every 15 minute checks for this episode. A nursing note dated 07/17/16 indicated at 6:57 p.m., Resident #1 was very agitated, unable to re-direct, and was combative with other residents and staff. During an observation on 07/26/16 at 9:21 a.m., in the secure unit, three residents were in an altercation in the sitting area. The administrator was the nearest staff present and he was immediately notified by the surveyor. Resident #1 and Resident #3 were on the floor. Resident #1 was on the right side of Resident #3. Resident #1 had his left arm wrapped around Resident #3's neck, and he was hitting Resident #3 with his other arm. Resident #4 was standing at the area where Resident #3's lower legs were located and she was kicking Resident #3's lower legs. Resident #3 had a small area of blood on his forehead and blood on his left ear. There were no staff present in the area when this altercation was observed. The administrator began intervening and yelling for assistance. LVN B came from down the hall and assisted. The administrator informed staff to place residents on one-on-one supervision. A nursing note dated 07/26/16 at 2:11 p.m., indicated Resident #1 was placed on every 15 minute checks starting at 10:30 a.m. A nursing note dated 07/26/16 indicated at 1:28 p.m., Resident #1 punched LVN B on the side of the face and then began choking her. Three staff members had to help LVN B get out of the choke hold. Resident #1 was also biting at the nurse while choking her. The resident was given medication and then returned to the nursing station where he tried to punch the nurse again. During an interview on 07/26/16 at 12:51 p.m., LVN B said at approximately 10:50 a.m. she was in the hallway and Resident #1 came up behind her and hit her very hard on the side of her head. He then immediately wrapped his arm around her neck and put her in a choke hold, squeezing her neck hard. She said it took several staff to release the hold. She said her head, throat, and neck hurt. LVN B said Resident #1 had frequent aggressive behaviors, at least two or more episodes a week. She said Resident #1 needed very close monitoring and one-on-one supervision. During an interview on 06/26/16 at 1:40 p.m., the acting DON said Resident #1 was currently on every 15 minute checks. 2. Physician orders [REDACTED].#4 was [AGE] years old, was admitted [DATE], with [DIAGNOSES REDACTED]. The Interim Care Plan dated 07/18/16 for Resident #4 did not address behaviors. A nursing note dated 07/19/16 indicated at 5:30 p.m., Resident #4 was combative, agitated, and hitting any staff close to her. A nursing note dated 07/20/16 indicated at 8:33 a.m., Resident #4 was combative, hitting and pinching staff during care. A nursing note dated 07/24/16 indicated at 1:45 a.m., Resident #4 was noted to display mood swings. A nursing note dated 07/25/16 indicated at 10:36 a.m., Resident #4 was very combative during her shower this morning and slapped a nurse and hospice aide. During an interview on 07/26/16 at 12:51 p.m., LVN B said Resident #4 has aggressive and combative behaviors on a daily basis. She said the resident needed to be monitored closely to talk her down and keep her from hitting others. She said one moment Resident #4 was fine and the next moment she was extremely aggressive and combative. LVN B said a couple of days ago, Resident #4 became upset with Resident #3 and she began attacking him and pushing him into the wall. During an interview on 07/26/16 at 2:01 p.m., CNA C said Resident #4 had frequent behaviors. The resident was fine one moment and then she was very angry the next. CNA C said Resident #4 needed close supervision. During an observation on 07/26/16 at 9:21 a.m., in the secure unit, three residents were in an altercation in the sitting area. The administrator was the nearest staff present and he was immediately notified by the surveyor. Resident #1 and Resident #3 were on the floor. Resident #1 was on the right side of Resident #3. Resident #1 had his left arm wrapped around Resident #3's neck, and he was hitting Resident #3 with his other arm. Resident #4 was standing at the area where Resident #3's lower legs were located and she was kicking Resident #3's lower legs. Resident #3 had a small area of blood on his forehead and blood on his left ear. There were no staff present in the area when this altercation was observed. The administrator began intervening and yelling for assistance. LVN B came from down the hall and assisted. The administrator informed staff to place residents on one-on-one supervision. 3. Physician orders [REDACTED].#3 was [AGE] years old, was admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 was severely cognitively impaired, and had exhibited no physical behaviors. The Care Plan dated 06/09/16 for Resident #3 did not address behaviors. An Incident Report dated 06/11/16 indicated at 4:18 p.m., Resident #3 had an altercation with another resident and struck him. The hit was witnessed by staff, but staff were unable to get to the two residents before the physical altercation began. A nursing note dated 07/09/16 indicated at 7:42 p.m., Resident #3 was aggressive with staff at times and difficult to re-direct. A nursing note dated 07/17/16 indicated at 8:06 a.m., Resident #3 was aggressive, agitated, and difficult to re-direct. A nursing note dated 07/17/16 indicated at 6:46 p.m., Resident #3 was aggressive and agitated with staff and other residents, was slamming his fists against the nursing station, and was unable to re-direct. During an interview on 07/26/16 at 12:51 p.m., LVN B said Resident #3 had frequent behaviors and tried to hit the female residents. She said the resident tried to hit one of the female residents yesterday and she intervened. She said Resident #3 liked to touch the female residents on their shoulders; the female residents did not like that and it upset Resident #3. She said Resident #3 needed close supervision. The administrator was notified, on 07/26/16 at 1:42 p.m., that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on 07/26/16 at 4:45 p.m. and included: 1. Resident #4 has been discharged as of 07/26/16. 2. Resident #3 and Resident #1 will be moved from every 15 minute checks to one-on-one monitoring until they can be discharged safely. Schedule of which staff would be monitoring each resident was included, and the staffing levels were increased to ensure normal staff numbers plus those staff assigned to the one-on-one monitoring of residents. 3. All residents in secure unit will be assessed for aggressive behaviors to ensure plan of care is being properly followed for medication administration. 4. Any resident found to continue to exhibit aggressive behaviors will be discharged immediately pending proper placement. On 07/27/16, the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Resident #s 1, 3, and 4 had been discharged from the facility. All residents on the secure unit had been evaluated for aggressive behaviors. Facility was in the process of in-servicing all staff concerning reactions to behaviors and incident reporting. Conducted interviews with 2 of the 3 staff that were present in the secure unit, who responded correctly concerning reactions to resident behaviors. On 07/27/16 at 1:15 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm, due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. The Resident Listing Report dated 07/26/16 indicated 20 residents resided on the secure unit.

Based on observation, interview, and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 3 of 5 residents reviewed for neglect and supervision. (Resident #s 1, 2, 3, and 4) The facility did not implement interventions to prevent Residents #1,#3, and #4 from attacking others. These 3 residents exhibited patterns of aggressive behaviors toward other residents and the staff. All 3 of these residents were fighting without staff in the immediate area. After surveyor intervention, the administrator stopped the altercation and placed all three on 1:1 supervision. Later that day, Resident #1 punched and choked LVN B. The facility did not prevent Resident #1 from attacking Resident #2, and placing him in a choke hold. An Immediate Jeopardy situation was identified on 07/26/16. The Immediate Jeopardy was removed on 07/27/16. The facility remained out of compliance at a pattern of potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 20 residents on the secure unit at risk of severe injuries. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, was admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was severely cognitively impaired and had physical behaviors directed towards others four to six times a week. The Care Plan dated 07/01/16 indicated Resident #1 had behaviors of physical aggression, being combative, and agitation. The interventions listed included: re-direct as needed, assist resident with coping mechanisms, allow choices, anticipate needs, administer medications as ordered, and analyze triggers. An Incident Report dated 06/26/16 indicated at 2:30 p.m., Resident #1 attacked CNA A from behind, placed his arm around her neck, and pushed her to the floor. During an interview on 07/26/16 at 1:53 p.m., CNA A said she was in the shower bathing another resident. She said Resident #1 came into the shower room, came up behind her, wrapped his arm around her neck, and put her in a tight choke hold. She said the pressure the resident was applying to her neck was painful. She said the resident took her to the floor. She said she was unable to notify other staff, and no staff came to help her. She said another resident in the room who she had been bathing came to help her. CNA A said she could finally get up and get other staff for help. She said her throat and neck hurt for several days. She said Resident #1 was aggressive and she felt he needed one-on-one supervision. A nursing note dated 06/26/16 indicated at 2:39 p.m. (following the shower incident), Resident #1 was placed on 15 minute checks. A nursing note dated 06/30/16 at 10:35 a.m., indicated Resident #1 would be taken off of 15 minute checks at 2:00 p.m. that day. A nursing note dated 07/02/16 indicated at 4:27 p.m., Resident #1 was combative with staff. The resident was in a female's room and attempted to attack staff when they tried to remove him. A nursing note dated 07/08/16 indicated at 1:21 a.m., Resident #1 was combative with staff, very agitated, and tried to hit staff when re-directed. An Incident Report dated 07/14/16 indicated at 10:00 a.m., Resident #1 attacked Resident #2. LVN B heard residents yelling and went to Resident #2's room. She found Resident #1 had Resident #2 in a choke hold and was hitting him. LVN B separated the residents. The incident report indicated Resident #1 was aggressive at times and he was placed on 15 minute checks. A nursing note dated 07/17/16 at 2:05 p.m., was the last mention of Resident #1 being on every 15 minute checks for this episode. A nursing note dated 07/17/16 indicated at 6:57 p.m., Resident #1 was very agitated, unable to re-direct, and was combative with other residents and staff. During an observation on 07/26/16 at 9:21 a.m., in the secure unit, three residents were in an altercation in the sitting area. The administrator was the nearest staff present and he was immediately notified by the surveyor. Resident #1 and Resident #3 were on the floor. Resident #1 was on the right side of Resident #3. Resident #1 had his left arm wrapped around Resident #3's neck, and he was hitting Resident #3 with his other arm. Resident #4 was standing at the area where Resident #3's lower legs were located and she was kicking Resident #3's lower legs. Resident #3 had a small area of blood on his forehead and blood on his left ear. There were no staff present in the area when this altercation was observed. The administrator began intervening and yelling for assistance. LVN B came from down the hall and assisted. The administrator informed staff to place residents on one-on-one supervision. A nursing note dated 07/26/16 at 2:11 p.m., indicated Resident #1 was placed on every 15 minute checks starting at 10:30 a.m. A nursing note dated 07/26/16 indicated at 1:28 p.m., Resident #1 punched LVN B on the side of the face and then began choking her. Three staff members had to help LVN B get out of the choke hold. Resident #1 was also biting at the nurse while choking her. The resident was given medication and then returned to the nursing station where he tried to punch the nurse again. During an interview on 07/26/16 at 12:51 p.m., LVN B said at approximately 10:50 a.m. she was in the hallway and Resident #1 came up behind her and hit her very hard on the side of her head. He then immediately wrapped his arm around her neck and put her in a choke hold, squeezing her neck hard. She said it took several staff to release the hold. She said her head, throat, and neck hurt. LVN B said Resident #1 had frequent aggressive behaviors, at least two or more episodes a week. She said Resident #1 needed very close monitoring and one-on-one supervision. During an interview on 06/26/16 at 1:40 p.m., the acting DON said Resident #1 was currently on every 15 minute checks. 2. Physician orders [REDACTED].#4 was [AGE] years old, was admitted [DATE], with [DIAGNOSES REDACTED]. The Interim Care Plan dated 07/18/16 for Resident #4 did not address behaviors. A nursing note dated 07/19/16 indicated at 5:30 p.m., Resident #4 was combative, agitated, and hitting any staff close to her. A nursing note dated 07/20/16 indicated at 8:33 a.m., Resident #4 was combative, hitting and pinching staff during care. A nursing note dated 07/24/16 indicated at 1:45 a.m., Resident #4 was noted to display mood swings. A nursing note dated 07/25/16 indicated at 10:36 a.m., Resident #4 was very combative during her shower this morning and slapped a nurse and hospice aide. During an interview on 07/26/16 at 12:51 p.m., LVN B said Resident #4 has aggressive and combative behaviors on a daily basis. She said the resident needed to be monitored closely to talk her down and keep her from hitting others. She said one moment Resident #4 was fine and the next moment she was extremely aggressive and combative. LVN B said a couple of days ago, Resident #4 became upset with Resident #3 and she began attacking him and pushing him into the wall. During an interview on 07/26/16 at 2:01 p.m., CNA C said Resident #4 had frequent behaviors. The resident was fine one moment and then she was very angry the next. CNA C said Resident #4 needed close supervision. During an observation on 07/26/16 at 9:21 a.m., in the secure unit, three residents were in an altercation in the sitting area. The administrator was the nearest staff present and he was immediately notified by the surveyor. Resident #1 and Resident #3 were on the floor. Resident #1 was on the right side of Resident #3. Resident #1 had his left arm wrapped around Resident #3's neck, and he was hitting Resident #3 with his other arm. Resident #4 was standing at the area where Resident #3's lower legs were located and she was kicking Resident #3's lower legs. Resident #3 had a small area of blood on his forehead and blood on his left ear. There were no staff present in the area when this altercation was observed. The administrator began intervening and yelling for assistance. LVN B came from down the hall and assisted. The administrator informed staff to place residents on one-on-one supervision. 3. Physician orders [REDACTED].#3 was [AGE] years old, was admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 was severely cognitively impaired, and had exhibited no physical behaviors. The Care Plan dated 06/09/16 for Resident #3 did not address behaviors. An Incident Report dated 06/11/16 indicated at 4:18 p.m., Resident #3 had an altercation with another resident and struck him. The hit was witnessed by staff, but staff were unable to get to the two residents before the physical altercation began. A nursing note dated 07/09/16 indicated at 7:42 p.m., Resident #3 was aggressive with staff at times and difficult to re-direct. A nursing note dated 07/17/16 indicated at 8:06 a.m., Resident #3 was aggressive, agitated, and difficult to re-direct. A nursing note dated 07/17/16 indicated at 6:46 p.m., Resident #3 was aggressive and agitated with staff and other residents, was slamming his fists against the nursing station, and was unable to re-direct. During an interview on 07/26/16 at 12:51 p.m., LVN B said Resident #3 had frequent behaviors and tried to hit the female residents. She said the resident tried to hit one of the female residents yesterday and she intervened. She said Resident #3 liked to touch the female residents on their shoulders; the female residents did not like that and it upset Resident #3. She said Resident #3 needed close supervision. The Abuse and Neglect Prohibition Policy dated 06/13 indicated each resident has the right to be free from neglect. The administrator was notified, on 07/26/16 at 1:42 p.m., that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on 07/26/16 at 4:45 p.m. and included: 1. Resident #4 has been discharged as of 07/26/16. 2. Resident #3 and Resident #1 will be moved from every 15 minute checks to one-on-one monitoring until they can be discharged safely. Schedule of which staff would be monitoring each resident was included, and the staffing levels were increased to ensure normal staff numbers plus those staff assigned to the one-on-one monitoring of residents. 3. All residents in secure unit will be assessed for aggressive behaviors to ensure plan of care is being properly followed for medication administration. 4. Any resident found to continue to exhibit aggressive behaviors will be discharged immediately pending proper placement. On 07/27/16, the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Resident #s 1, 3, and 4 had been discharged from the facility. All residents on the secure unit had been evaluated for aggressive behaviors. Facility was in the process of in-servicing all staff concerning reactions to behaviors and incident reporting. Conducted interviews with 2 of the 3 staff that were present in the secure unit, who responded correctly concerning reactions to resident behaviors. On 07/27/16 at 1:15 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm, due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. The Resident Listing Report dated 07/26/16 indicated 20 residents resided on the secure unit.

Based on observation, interview, and record review, the facility failed to promptly notify the physician of abnormal x-ray results for 1 or 10 residents reviewed for laboratory/x-ray services. (Resident #1) The facility did not notify the physician of Resident #1's chest x-ray that indicated Resident #1 had pneumonia in both of his lungs. He died 5 days after the x-ray when his respiratory status continued to deteriorate. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 91 residents at risk for serious injury or possible death. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #1's baseline respirations were 20 breaths a minute and oxygen saturation level was 97%. According to the website, http://www.medguidance.com/thread/Oxygen-Saturation-Levels, accessed [DATE], oxygen saturation levels, they are referring to the extent of haemoglobin that is saturated with oxygen and .normal oxygen saturation level is between 95% to 100% . Nursing notes dated [DATE] at 3:00 p.m., indicated Resident #1 wandered out the door and was found walking on a sidewalk by the facility. Resident #1 was escorted back in the building and assisted to his wheelchair. The notes indicated Resident #1 said he was walking out of the facility. Nursing notes dated [DATE] at 8:29 a.m., indicated Resident #1 ambulated down the hall and attempted to elope out the back door. He was assisted back to his wheelchair by staff. Resident #1 said he was going home. Nursing notes dated [DATE] at 4:05 a.m., indicated Resident #1 ' s oxygen saturation level was 96% (his baseline was 97%). Nursing notes dated [DATE] at 9:22 a.m., indicated Resident #1 demanded staff to push him down the hall in his wheelchair to be let out of the facility. [MEDICATION NAME] (anti-anxiety medication) was administered to Resident #1. An oxygen saturation level log for Resident #1 indicated his oxygen saturation levels included the following: (Baseline 97%) *[DATE] - 93%, *[DATE] - 94%. The log did not indicate if the resident's respiratory status was assessed or if the physician was consulted. Nursing notes dated [DATE] at 1:45 p.m., indicated Resident #1 said he called for assistance for a long time, but nobody came to his room. He said he needed to go to the bathroom. Resident #1 was assisted back to his room and he was getting short of breath. Oxygen was placed on the resident and he received a breathing treatment with good results. Nursing notes dated [DATE] at 7:00 p.m., indicated Resident #1 was not able to support himself in a seated position. Resident #1 was becoming increasingly lethargic and agitated. He developed a productive cough and was short of breath at rest. The notes did not indicate if the nurse assessed the resident or consulted with the physician. Nursing notes dated [DATE] at 6:40 p.m., indicated Resident #1 had labored respirations, he was short of breath, and was mouth breathing. He did not eat breakfast or lunch. The notes did not indicate if the physician was consulted or if the nurse applied oxygen for respiratory support. Nursing notes dated [DATE] at 1:57 p.m., indicated Resident #1 was noted to have difficulty breathing, was coughing, and was wheezing. The notes did not indicate if the physician was consulted or if the nurse applied oxygen for respiratory support or any other intervention. Nursing notes dated [DATE] at 2:01 p.m., indicated the on call doctor was notified of Resident #1's condition and a STAT (immediate) chest x-ray was ordered. During a telephone interview on [DATE] at 9:01 a.m., LVN A said she worked on [DATE] and was covering for LVN B (who was responsible for Resident #1) while LVN B was at lunch. She said Resident #1 was having difficulty breathing and did not look good. She said she called the on call doctor who ordered a chest x-ray. She said there was no follow up on the x-ray even though she told LVN B that she ordered the chest x-ray. LVN A said when she left on Sunday, she did not come back until the next Saturday and Resident #1 was deceased when she returned the following Saturday ([DATE]). During an interview on [DATE] at 11:30 a.m., LVN C said on [DATE], she went into Resident #1's room with LVN A. She said Resident #1 was pale and was having difficulty breathing. She said she thought he had a change of condition and that was why LVN A ordered the chest x-ray. LVN C thought Resident #1 would be sent out to the hospital for further evaluation. She said she did not know if anything else was done for Resident #1. During an interview on [DATE] at 2:57 p.m., LVN B said LVN A covered her shift while she went to lunch and ordered a chest x-ray for Resident #1. She said when she came back from lunch, LVN A told her she needed to check on Resident #1 and follow up on the chest x-ray. She said she went into Resident #1's room and he was breathing like he always did. LVN B said she did not assess Resident #1. She said normally x-ray results were faxed, but she did not receive Resident #1's chest x-ray results and she did not call the x-ray company to get the results. She said she told the oncoming nurse that the resident had a chest x-ray and wrote it on the 24 hour report for [DATE], but it was not transferred to the 24 hour report for [DATE]. A STAT (immediate) chest x-ray result dated [DATE] for Resident #1 indicated he had pneumonia in both of his lungs and the word ALERT was written across the results. During a telephone interview on [DATE] at 1:20 p.m., the on call doctor's nurse said the facility did not call the on call doctor to notify him of the x-ray results. A 24-hour report sheet dated [DATE] indicated Resident #1 received a chest x-ray and was short of breath. The [DATE] 24-hour report did not contain any other information regarding Resident #1. During an interview on [DATE] at 1:30 p.m., the DON said Resident #1's physician was not notified of results of the chest x-ray. She said normal procedure would be to fax the doctor with the results, but the fax machine was not working properly on [DATE]. She said LVN B told her Resident #1 was agitated on [DATE]. She said she was not aware that Resident #1 had pneumonia. Nursing notes dated [DATE] at 11:20 a.m., indicated the NP was notified of Resident #1's declining strength and poor food intake. The NP said to make him an appointment with his primary doctor to talk about hospice. The notes did not indicate if the NP was notified of the resident's x-ray results. Nursing notes dated [DATE] at 5:52 a.m., indicated Resident #1 occasionally yelled out for help. Resident #1 became easily short of breath and had increased weakness with mobility. Nursing notes dated [DATE] at 10:55 p.m., indicated Resident #1 continued to decline. Resident #1 did not eat or drink fluids the entire day. His oxygen saturation levels were 88%-90% (his baseline was 97%). Nursing notes dated [DATE] at 5:40 a.m., indicated Resident #1 continued to decline and his skin was pale and warm. Resident #1's respirations were shallow and he was short of breath. Resident #1's oxygen saturation levels remained between 86%-90% (his baseline was 97%). He required maximum assistance of 2 staff with ADLs and mobility. Nursing notes dated [DATE] at 7:10 a.m., indicated Resident #1 was not doing good at all. Resident #1's oxygen saturation was 89% and his respirations were 32 breaths a minute, and were rapid and shallow. Resident #1 moaned a little to a sternal rub (his baseline was 20 breaths a minute and 97% oxygen saturation level). Nursing notes dated [DATE] at 9:46 a.m., indicated Resident #1 received a new order for [MEDICATION NAME] for comfort measures. Nursing notes dated [DATE] at 2:30 p.m., indicated Resident #1 was lying in bed with his eyes and mouth open, and responded to sternal rub only. Resident #1's oxygen saturation level was 91% (his baseline was 97%) and [MEDICATION NAME] was given to Resident #1 for comfort measures. An oxygen saturation level log for Resident #1 indicated his oxygen saturation levels from [DATE] through [DATE] and [DATE]- [DATE] were between 95%-98%. Nursing notes dated [DATE] at 12:20 a.m., indicated Resident #1 was grimacing and had shortness of breath with shallow respirations. Resident #1's oxygen saturation level was 78% (his baseline was 97%) and his skin was hot to touch. He had occasional apnea episodes (not breathing) [MEDICATION NAME] up to 10 seconds. [MEDICATION NAME] was administered to Resident #1 for comfort. Nursing notes dated [DATE] at 1:00 a.m., indicated Resident #1 was resting quietly with shallow respirations. Resident #1 had mottling to all 4 extremities and his skin was hot to touch. Resident #1 was unresponsive to touch or verbal stimuli. Nursing notes dated [DATE] at 1:45 a.m., indicated Resident #1 was pronounced dead by an RN. During an interview on [DATE] at 2:10 p.m., CNA D said Resident #1 had a rapid decline in the last week of his life. She said his breathing and his appearance were dramatically worse. During a telephone interview on [DATE] at 11:17 a.m., Resident #1's primary physician's nurse said they were not notified of Resident #1's pneumonia. She said the only communication they received about Resident #1 was a fax on [DATE] about the resident expiring. During a telephone interview on [DATE] at 12:33 p.m., the NP said she did not know Resident #1 had expired. She said the facility called her the previous week to notify her of Resident #1's decline in health, but the facility did not notify her that he had pneumonia. She said if the facility would have notified her of Resident #1's pneumonia, she would have ordered him an antibiotic. During an interview on [DATE] at 3:45 p.m., the administrator said he knew Resident #1 had pneumonia, but did not know any more details. During an interview on [DATE] at 3:50 p.m., the corporate nurse said she knew a chest x-ray was ordered for Resident #1 and the physician was not notified of the results of the chest x-ray. The Changes in Resident Condition Policy revised [DATE], indicated the resident, the attending physician, and family member would be notified when changes in condition occurred. Communication with the interdisciplinary team and caregivers was also important to ensure that consistency and continuity were maintained. Changes in condition were communicated from shift to shift though the 24 hour report. The administrator was notified on [DATE] at 4:19 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility ' s revised Plan of Removal was accepted on [DATE] at 7:18 p.m. and included: 1. Nurses will be re-educated on MD/Family notification of change in resident condition. 2. Nurses will be re-educated on documentation in resident charts on changes in condition. 3. Nurses will be re-educated on resident assessments as it relates to changes in condition. 4. Nurses will be re-educated to notify physician by telephone when receiving abnormal diagnostic results, and documenting response in medical record, and follow-through with orders when indicated. 5. Nursing administrative staff will review resident charts to ensure previously ordered diagnostic tests have been followed-through with MD notification. 6.Nurses will be re-educated on process of ordering diagnostic testing to included orders, MD & family notification, documentation, and following-up with results or inability to obtain testing. 7. Educate nurses on physical assessments. 8. Educate nurses to follow-up at beginning of shift on all pending diagnostic tests from pervious shift, and calling if they haven ' t received results. Target completion date will be ,[DATE]/ or prior to the start of the next scheduled shift. (sic) On [DATE] the surveyors confirmed the POR was implemented sufficiently to remove the Immediate Jeopardy by: Two RNs, 3 LVNs, and 1 LVN (ADON) were in-serviced on MD/family notification of change in resident condition, documentation in resident charts and change in condition, resident assessments, notifying physicians by phone of abnormal diagnostic results, and following up on results. Ten residents' charts were reviewed for ordered, pending diagnostic testing, and MD notification of results. All were correct and complete. On [DATE] at 2:20 p.m., the administrator, corporate nurse, DON, and ADON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. The resident roster dated [DATE] indicated there were 91 residents in the facility.

Based on observation, interview, and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 2 of 10 residents reviewed for neglect. (Residents #1 and #3) 1. Resident #1 had a significant change in his condition and experienced respiratory distress for over a week. The facility did not recognize progressive symptoms or assess Resident #1 when he had a decline in condition and experienced respiratory distress. The facility did not consult with the physician regarding the resident ' s continuous decline and of an abnormal chest x-ray. Resident #1 continued to decline and died 5 days after his condition began to deteriorate and the abnormal x-ray was obtained. 2. The facility did not: * ensure Resident #3 did not receive medications, to which she was allergic. She received 5 doses. * perform blood sugar checks as ordered by the physician. * perform neurological assessments as ordered following a fall. Resident #3 died 2 hours after the reported fall. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 91 residents at risk for serious injury or possible death. Findings included: 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #1's baseline respirations were 20 breaths a minute and oxygen saturation level was 97%. According to the website, http://www.medguidance.com/thread/Oxygen-Saturation-Levels, accessed [DATE], oxygen saturation levels, they are referring to the extent of haemoglobin that is saturated with oxygen and .normal oxygen saturation level is between 95% to 100% . Nursing notes dated [DATE] at 3:00 p.m., indicated Resident #1 wandered out the door and was found walking on a sidewalk by the facility. Resident #1 was escorted back in the building and assisted to his wheelchair. The notes indicated Resident #1 said he was walking out of the facility. Nursing notes dated [DATE] at 8:29 a.m., indicated Resident #1 ambulated down the hall and attempted to elope out the back door. He was assisted back to his wheelchair by staff. Resident #1 said he was going home. Nursing notes dated [DATE] at 4:05 a.m., indicated Resident #1's oxygen saturation level was 96% (his baseline was 97%). Nursing notes dated [DATE] at 9:22 a.m., indicated Resident #1 demanded staff to push him down the hall in his wheelchair to be let out of the facility. [MEDICATION NAME] (anti-anxiety medication) was administered to Resident #1. An oxygen saturation level log for Resident #1 indicated his oxygen saturation levels included the following: (Baseline 97%) *[DATE] - 93%, *[DATE] - 94%. The log did not indicate if the resident's respiratory status was assessed or if the physician was consulted. Nursing notes dated [DATE] at 1:45 p.m., indicated Resident #1 said he called for assistance for a long time, but nobody came to his room. He said he needed to go to the bathroom. Resident #1 was assisted back to his room and he was getting short of breath. Oxygen was placed on the resident and he received a breathing treatment with good results. Nursing notes dated [DATE] at 7:00 p.m., indicated Resident #1 was not able to support himself in a seated position. Resident #1 was becoming increasingly lethargic and agitated. He developed a productive cough and was short of breath at rest. The notes did not indicate if the nurse assessed the resident or consulted with the physician. Nursing notes dated [DATE] at 6:40 p.m., indicated Resident #1 had labored respirations, he was short of breath, and was mouth breathing. He did not eat breakfast or lunch. The notes did not indicate if the physician was consulted or if the nurse applied oxygen for respiratory support. Nursing notes dated [DATE] at 1:57 p.m., indicated Resident #1 was noted to have difficulty breathing, was coughing, and was wheezing. The notes did not indicate if the physician was consulted or if the nurse applied oxygen for respiratory support or any other intervention. Nursing notes dated [DATE] at 2:01 p.m., indicated the on call doctor was notified of Resident #1' s condition and a STAT (immediate) chest x-ray was ordered. During a telephone interview on [DATE] at 9:01 a.m., LVN A said she worked on [DATE] and was covering for LVN B (who was responsible for Resident #1) while LVN B was at lunch. She said Resident #1 was having difficulty breathing and did not look good. She said she called the on call doctor who ordered a chest x-ray. She said there was no follow up on the x-ray even though she told LVN B that she ordered the chest x-ray. LVN A said when she left on Sunday, she did not come back until the next Saturday and Resident #1 was deceased when she returned the following Saturday ([DATE]). During an interview on [DATE] at 11:30 a.m., LVN C said on [DATE], she went into Resident #1's room with LVN A. She said Resident #1 was pale and was having difficulty breathing. She said she thought he had a change of condition and that was why LVN A ordered the chest x-ray. LVN C thought Resident #1 would be sent out to the hospital for further evaluation. She said she did not know if anything else was done for Resident #1. During an interview on [DATE] at 2:57 p.m., LVN B said LVN A covered her shift while she went to lunch and ordered a chest x-ray for Resident #1. She said when she came back from lunch, LVN A told her she needed to check on Resident #1 and follow up on the chest x-ray. She said she went into Resident #1's room and he was breathing like he always did. LVN B said she did not assess Resident #1. She said normally x-ray results were faxed, but she did not receive Resident #1's chest x-ray results and she did not call the x-ray company to get the results. She said she told the oncoming nurse that the resident had a chest x-ray and wrote it on the 24 hour report for [DATE], but it was not transferred to the 24 hour report for [DATE]. A STAT (immediate) chest x-ray result dated [DATE] for Resident #1 indicated he had pneumonia in both of his lungs and the word ALERT was written across the results. During a telephone interview on [DATE] at 1:20 p.m., the on call doctor's nurse said the facility did not call the on call doctor to notify him of the x-ray results. A 24-hour report sheet dated [DATE] indicated Resident #1 received a chest x-ray and was short of breath. The [DATE] 24-hour report did not contain any other information regarding Resident #1. During an interview on [DATE] at 1:30 p.m., the DON said Resident #1's physician was not notified of results of the chest x-ray. She said normal procedure would be to fax the doctor with the results, but the fax machine was not working properly on [DATE]. She said LVN B told her Resident #1 was agitated on [DATE]. She said she was not aware that Resident #1 had pneumonia. Nursing notes dated [DATE] at 11:20 a.m., indicated the NP was notified of Resident #1's declining strength and poor food intake. The NP said to make him an appointment with his primary doctor to talk about hospice. The notes did not indicate if the NP was notified of the resident's x-ray results. Nursing notes dated [DATE] at 5:52 a.m., indicated Resident #1 occasionally yelled out for help. Resident #1 became easily short of breath and had increased weakness with mobility. Nursing notes dated [DATE] at 10:55 p.m., indicated Resident #1 continued to decline. Resident #1 did not eat or drink fluids the entire day. His oxygen saturation levels were 88%-90% (his baseline was 97%). Nursing notes dated [DATE] at 5:40 a.m., indicated Resident #1 continued to decline and his skin was pale and warm. Resident #1's respirations were shallow and he was short of breath. Resident #1's oxygen saturation levels remained between 86%-90% (his baseline was 97%). He required maximum assistance of 2 staff with ADLs and mobility. Nursing notes dated [DATE] at 7:10 a.m., indicated Resident #1 was not doing good at all. Resident #1's oxygen saturation was 89% and his respirations were 32 breaths a minute, and were rapid and shallow. Resident #1 moaned a little to a sternal rub (his baseline was 20 breaths a minute and 97% oxygen saturation level). Nursing notes dated [DATE] at 9:46 a.m., indicated Resident #1 received a new order for [MEDICATION NAME] for comfort measures. Nursing notes dated [DATE] at 2:30 p.m., indicated Resident #1 was lying in bed with his eyes and mouth open, and responded to sternal rub only. Resident #1's oxygen saturation level was 91% (his baseline was 97%) and [MEDICATION NAME] was given to Resident #1 for comfort measures. An oxygen saturation level log for Resident #1 indicated his oxygen saturation levels from [DATE] through [DATE] and [DATE]- [DATE] were between 95%-98%. Nursing notes dated [DATE] at 12:20 a.m., indicated Resident #1 was grimacing and had shortness of breath with shallow respirations. Resident #1's oxygen saturation level was 78% (his baseline was 97%) and his skin was hot to touch. He had occasional apnea episodes (not breathing) [MEDICATION NAME] up to 10 seconds. [MEDICATION NAME] was administered to Resident #1 for comfort. Nursing notes dated [DATE] at 1:00 a.m., indicated Resident #1 was resting quietly with shallow respirations. Resident #1 had mottling to all 4 extremities and his skin was hot to touch. Resident #1 was unresponsive to touch or verbal stimuli. Nursing notes dated [DATE] at 1:45 a.m., indicated Resident #1 was pronounced dead by an RN. During an interview on [DATE] at 2:10 p.m., CNA D said Resident #1 had a rapid decline in the last week of his life. She said his breathing and his appearance were dramatically worse. During a telephone interview on [DATE] at 11:17 a.m., Resident #1'ss primary physician's nurse said they were not notified of Resident #1's pneumonia. She said the only communication they received about Resident #1 was a fax on [DATE] about the resident expiring. During a telephone interview on [DATE] at 12:33 p.m., the NP said she did not know Resident #1 had expired. She said the facility called her the previous week to notify her of Resident #1's decline in health, but the facility did not notify her that he had pneumonia. She said if the facility would have notified her of Resident #1's pneumonia, she would have ordered him an antibiotic. During an interview on [DATE] at 3:45 p.m., the administrator said he knew Resident #1 had pneumonia, but did not know any more details. During an interview on [DATE] at 3:50 p.m., the corporate nurse said she knew a chest x-ray was ordered for Resident #1 and the physician was not notified of the results of the chest x-ray. 2. Physician orders [REDACTED].#3, [AGE] years old, was admitted on [DATE] and was a Do Not Resuscitate status (DNR). Her [DIAGNOSES REDACTED]. The final orders also indicated she expired in the facility on [DATE]. Nursing notes dated [DATE] at 11:11 a.m., indicated Resident #3 had a reddened, open area to her left lower leg and the doctor was notified. A new order for the antibiotic [MEDICATION NAME] was received. Physician orders [REDACTED].#3 was ordered [MEDICATION NAME] (antibiotic) 300 mg to be given by mouth three times a day for a wound infection. A computerized MAR for [DATE] indicated Resident #3 was allergic to [MEDICATION NAME], fish, iodine, [MEDICATION NAME], and [MEDICATION NAME]. Nursing notes dated [DATE] at 2:00 p.m., indicated Resident #3 was ordered [MEDICATION NAME] 300 mg, three times a day. The notes indicated prior to the administration of the first oral dose of the [MEDICATION NAME], Resident #3 said intravenous [MEDICATION NAME] made her skin itch. The initial dose of [MEDICATION NAME] was given. A hand-written MAR for [DATE], that included the order for [MEDICATION NAME] 300 mg, three times a day, did not include Resident #3's allergies [REDACTED]. An incident report dated [DATE] indicated at 5:30 a.m., Resident #3 attempted to get out of bed to use the bathroom, lost her balance, and sat on the floor. The incident report indicated Resident #3 did not have any injuries; her vital signs were within normal limits. A neurological record dated [DATE] indicated 30 minute neurological checks were initiated at 6:00 a.m., Vital signs were documented as the same as the incident report. The 6:00 a.m. neurological check indicated Resident #3 was drowsy, opened her eyes to speech, and she flexed all four of her extremities abnormally. No further neurological checks were documented. A MAR for [DATE] indicated Resident #3's blood sugar was to be checked at 6:30 a.m. There was no entry for Resident #3's blood sugar on [DATE]. Nursing notes dated [DATE] at 7:15 a.m., indicated Resident #3 was lying on her bed with her eyes closed. Resident #3's lips were purple and mottling was noted to her right arm and hand. Resident #3 was unresponsive with no blood pressure and no pulse. The Abuse/Neglect Policy revised [DATE], indicated neglect was the failure to provide goods and services necessary to avoid physical harm. Facility supervisors would immediately correct and intervene in reported or identified situations in which neglect was at risk for occurring. Immediate Jeopardy was a situation in which the provider ' s non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death of a resident. The Changes in Resident Condition Policy revised [DATE], indicated the resident, the attending physician, and family member would be notified when changes in condition occurred. Communication with the interdisciplinary team and caregivers was also important to ensure that consistency and continuity were maintained. Changes in condition were communicated from shift to shift though the 24 hour report. The administrator was notified on [DATE] at 4:19 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 7:18 p.m. and included: 1. Nurses will be re-educated on MD/Family notification of change in resident condition. 2. Nurses will be re-educated on documentation in resident charts on changes in condition. 3. Nurses will be re-educated on resident assessments as it relates to changes in condition. 4. Nurses will be re-educated to notify physician by telephone when receiving abnormal diagnostic results, and documenting response in medical record, and follow-through with orders when indicated. 5. Nursing administrative staff will review resident charts to ensure previously ordered diagnostic tests have been followed-through with MD notification. 6.Nurses will be re-educated on process of ordering diagnostic testing to included orders, MD & family notification, documentation, and following-up with results or inability to obtain testing. 7. Educate nurses on physical assessments. 8. Educate nurses to follow-up at beginning of shift on all pending diagnostic tests from pervious shift, and calling if they haven ' t received results. Target completion date will be ,[DATE]/ or prior to the start of the next scheduled shift. (sic) On [DATE] the surveyors confirmed the POR was implemented sufficiently to remove the Immediate Jeopardy by: Two RNs, 3 LVNs, and 1 LVN (ADON) were in-serviced on MD/family notification of change in resident condition, documentation in resident charts and change in condition, resident assessments, notifying physicians by phone of abnormal diagnostic results, and following up on results. Ten residents' charts were reviewed for ordered, pending diagnostic testing, and MD notification of results. All were correct and complete. On [DATE] at 2:20 p.m., the administrator, corporate nurse, DON, and ADON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The resident roster dated [DATE] indicated there were 91 residents in the facility.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment to maintain the highest practicable well-being for 2 of 10 residents reviewed for assessments. Residents #1 and #3) 1. Resident #1 had a significant change in his condition and experienced respiratory distress for over a week. The facility did not recognize progressive symptoms or assess Resident #1 when he had a decline in condition and experienced respiratory distress. The facility did not consult with the physician regarding the resident ' s continuous decline and of an abnormal chest x-ray. Resident #1 continued to decline and died 5 days after his condition began to deteriorate and the abnormal x-ray was obtained. 2. The facility did not: * ensure Resident #3 did not receive medications, to which she was allergic. She received 5 doses. * perform blood sugar checks as ordered by the physician. * perform neurological assessments as ordered following a fall. Resident #3 died 2 hours after the reported fall. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 91 residents at risk for serious injury or possible death. Findings included: 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #1's baseline respirations were 20 breaths a minute and oxygen saturation level was 97%. According to the website, http://www.medguidance.com/thread/Oxygen-Saturation-Levels, accessed [DATE], oxygen saturation levels, they are referring to the extent of haemoglobin that is saturated with oxygen and .normal oxygen saturation level is between 95% to 100% . Nursing notes dated [DATE] at 3:00 p.m., indicated Resident #1 wandered out the door and was found walking on a sidewalk by the facility. Resident #1 was escorted back in the building and assisted to his wheelchair. The notes indicated Resident #1 said he was walking out of the facility. Nursing notes dated [DATE] at 8:29 a.m., indicated Resident #1 ambulated down the hall and attempted to elope out the back door. He was assisted back to his wheelchair by staff. Resident #1 said he was going home. Nursing notes dated [DATE] at 4:05 a.m., indicated Resident #1's oxygen saturation level was 96% (his baseline was 97%). Nursing notes dated [DATE] at 9:22 a.m., indicated Resident #1 demanded staff to push him down the hall in his wheelchair to be let out of the facility. [MEDICATION NAME] (anti-anxiety medication) was administered to Resident #1. An oxygen saturation level log for Resident #1 indicated his oxygen saturation levels included the following: (Baseline 97%) *[DATE] - 93%, *[DATE] - 94%. The log did not indicate if the resident's respiratory status was assessed or if the physician was consulted. Nursing notes dated [DATE] at 1:45 p.m., indicated Resident #1 said he called for assistance for a long time, but nobody came to his room. He said he needed to go to the bathroom. Resident #1 was assisted back to his room and he was getting short of breath. Oxygen was placed on the resident and he received a breathing treatment with good results. Nursing notes dated [DATE] at 7:00 p.m., indicated Resident #1 was not able to support himself in a seated position. Resident #1 was becoming increasingly lethargic and agitated. He developed a productive cough and was short of breath at rest. The notes did not indicate if the nurse assessed the resident or consulted with the physician. Nursing notes dated [DATE] at 6:40 p.m., indicated Resident #1 had labored respirations, he was short of breath, and was mouth breathing. He did not eat breakfast or lunch. The notes did not indicate if the physician was consulted or if the nurse applied oxygen for respiratory support. Nursing notes dated [DATE] at 1:57 p.m., indicated Resident #1 was noted to have difficulty breathing, was coughing, and was wheezing. The notes did not indicate if the physician was consulted or if the nurse applied oxygen for respiratory support or any other intervention. Nursing notes dated [DATE] at 2:01 p.m., indicated the on call doctor was notified of Resident #1's condition and a STAT (immediate) chest x-ray was ordered. During a telephone interview on [DATE] at 9:01 a.m., LVN A said she worked on [DATE] and was covering for LVN B (who was responsible for Resident #1) while LVN B was at lunch. She said Resident #1 was having difficulty breathing and did not look good. She said she called the on call doctor who ordered a chest x-ray. She said there was no follow up on the x-ray even though she told LVN B that she ordered the chest x-ray. LVN A said when she left on Sunday, she did not come back until the next Saturday and Resident #1 was deceased when she returned the following Saturday ([DATE]). During an interview on [DATE] at 11:30 a.m., LVN C said on [DATE], she went into Resident #1's room with LVN A. She said Resident #1 was pale and was having difficulty breathing. She said she thought he had a change of condition and that was why LVN A ordered the chest x-ray. LVN C thought Resident #1 would be sent out to the hospital for further evaluation. She said she did not know if anything else was done for Resident #1. During an interview on [DATE] at 2:57 p.m., LVN B said LVN A covered her shift while she went to lunch and ordered a chest x-ray for Resident #1. She said when she came back from lunch, LVN A told her she needed to check on Resident #1 and follow up on the chest x-ray. She said she went into Resident #1's room and he was breathing like he always did. LVN B said she did not assess Resident #1. She said normally x-ray results were faxed, but she did not receive Resident #1's chest x-ray results and she did not call the x-ray company to get the results. She said she told the oncoming nurse that the resident had a chest x-ray and wrote it on the 24 hour report for [DATE], but it was not transferred to the 24 hour report for [DATE]. A STAT (immediate) chest x-ray result dated [DATE] for Resident #1 indicated he had pneumonia in both of his lungs and the word ALERT was written across the results. During a telephone interview on [DATE] at 1:20 p.m., the on call doctor's nurse said the facility did not call the on call doctor to notify him of the x-ray results. A 24-hour report sheet dated [DATE] indicated Resident #1 received a chest x-ray and was short of breath. The [DATE] 24-hour report did not contain any other information regarding Resident #1. During an interview on [DATE] at 1:30 p.m., the DON said Resident #1's physician was not notified of results of the chest x-ray. She said normal procedure would be to fax the doctor with the results, but the fax machine was not working properly on [DATE]. She said LVN B told her Resident #1 was agitated on [DATE]. She said she was not aware that Resident #1 had pneumonia. Nursing notes dated [DATE] at 11:20 a.m., indicated the NP was notified of Resident #1' s declining strength and poor food intake. The NP said to make him an appointment with his primary doctor to talk about hospice. The notes did not indicate if the NP was notified of the resident's x-ray results. Nursing notes dated [DATE] at 5:52 a.m., indicated Resident #1 occasionally yelled out for help. Resident #1 became easily short of breath and had increased weakness with mobility. Nursing notes dated [DATE] at 10:55 p.m., indicated Resident #1 continued to decline. Resident #1 did not eat or drink fluids the entire day. His oxygen saturation levels were 88%-90% (his baseline was 97%). Nursing notes dated [DATE] at 5:40 a.m., indicated Resident #1 continued to decline and his skin was pale and warm. Resident #1's respirations were shallow and he was short of breath. Resident #1's oxygen saturation levels remained between 86%-90% (his baseline was 97%). He required maximum assistance of 2 staff with ADLs and mobility. Nursing notes dated [DATE] at 7:10 a.m., indicated Resident #1 was not doing good at all. Resident #1's oxygen saturation was 89% and his respirations were 32 breaths a minute, and were rapid and shallow. Resident #1 moaned a little to a sternal rub (his baseline was 20 breaths a minute and 97% oxygen saturation level). Nursing notes dated [DATE] at 9:46 a.m., indicated Resident #1 received a new order for [MEDICATION NAME] for comfort measures. Nursing notes dated [DATE] at 2:30 p.m., indicated Resident #1 was lying in bed with his eyes and mouth open, and responded to sternal rub only. Resident #1's oxygen saturation level was 91% (his baseline was 97%) and [MEDICATION NAME] was given to Resident #1 for comfort measures. An oxygen saturation level log for Resident #1 indicated his oxygen saturation levels from [DATE] through [DATE] and [DATE]- [DATE] were between 95%-98%. Nursing notes dated [DATE] at 12:20 a.m., indicated Resident #1 was grimacing and had shortness of breath with shallow respirations. Resident #1's oxygen saturation level was 78% (his baseline was 97%) and his skin was hot to touch. He had occasional apnea episodes (not breathing) [MEDICATION NAME] up to 10 seconds. [MEDICATION NAME] was administered to Resident #1 for comfort. Nursing notes dated [DATE] at 1:00 a.m., indicated Resident #1 was resting quietly with shallow respirations. Resident #1 had mottling to all 4 extremities and his skin was hot to touch. Resident #1 was unresponsive to touch or verbal stimuli. Nursing notes dated [DATE] at 1:45 a.m., indicated Resident #1 was pronounced dead by an RN. During an interview on [DATE] at 2:10 p.m., CNA D said Resident #1 had a rapid decline in the last week of his life. She said his breathing and his appearance were dramatically worse. During a telephone interview on [DATE] at 11:17 a.m., Resident #1 's primary physician's nurse said they were not notified of Resident #1's pneumonia. She said the only communication they received about Resident #1 was a fax on [DATE] about the resident expiring. During a telephone interview on [DATE] at 12:33 p.m., the NP said she did not know Resident #1 had expired. She said the facility called her the previous week to notify her of Resident #1's decline in health, but the facility did not notify her that he had pneumonia. She said if the facility would have notified her of Resident #1's pneumonia, she would have ordered him an antibiotic. During an interview on [DATE] at 3:45 p.m., the administrator said he knew Resident #1 had pneumonia, but did not know any more details. During an interview on [DATE] at 3:50 p.m., the corporate nurse said she knew a chest x-ray was ordered for Resident #1 and the physician was not notified of the results of the chest x-ray. 2. Physician orders [REDACTED].#3, [AGE] years old, was admitted on [DATE] and was a Do Not Resuscitate status (DNR). Her [DIAGNOSES REDACTED]. The final orders also indicated she expired in the facility on [DATE]. Nursing notes dated [DATE] at 11:11 a.m., indicated Resident #3 had a reddened, open area to her left lower leg and the doctor was notified. A new order for the antibiotic [MEDICATION NAME] was received. Physician orders [REDACTED].#3 was ordered [MEDICATION NAME] (antibiotic) 300 mg to be given by mouth three times a day for a wound infection. A computerized MAR for [DATE] indicated Resident #3 was allergic to [MEDICATION NAME], fish, iodine, [MEDICATION NAME], and [MEDICATION NAME]. Nursing notes dated [DATE] at 2:00 p.m., indicated Resident #3 was ordered [MEDICATION NAME] 300 mg, orally three times a day. The notes indicated prior to the administration of [MEDICATION NAME], Resident #3 said intravenous [MEDICATION NAME] made her skin itch. The initial dose of [MEDICATION NAME] was given. A hand-written MAR for [DATE], that included the order for [MEDICATION NAME] 300 mg, three times a day, did not include Resident #3's allergies [REDACTED]. An incident report dated [DATE] indicated at 5:30 a.m., Resident #3 attempted to get out of bed to use the bathroom, lost her balance, and sat on the floor. The incident report indicated Resident #3 did not have any injuries; her vital signs were within normal limits. A neurological record dated [DATE] indicated 30 minute neurological checks were initiated at 6:00 a.m., Vital signs were documented as the same as the incident report. The 6:00 a.m. neurological check indicated Resident #3 was drowsy, opened her eyes to speech, and she flexed all four of her extremities abnormally. No further neurological checks were documented. A MAR for [DATE] indicated Resident #3's blood sugar was to be checked at 6:30 a.m. There was no entry for Resident #3's blood sugar on [DATE]. Nursing notes dated [DATE] at 7:15 a.m., indicated Resident #3 was lying on her bed with her eyes closed. Resident #3 ' s lips were purple and mottling was noted to her right arm and hand. Resident #3 was unresponsive with no blood pressure and no pulse. The Changes in Resident Condition Policy revised [DATE], indicated the resident, the attending physician, and family member would be notified when changes in condition occurred. Communication with the interdisciplinary team and caregivers was also important to ensure that consistency and continuity were maintained. Changes in condition were communicated from shift to shift though the 24 hour report. The administrator was notified on [DATE] at 4:19 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 7:18 p.m. and included: 1. Nurses will be re-educated on MD/Family notification of change in resident condition. 2. Nurses will be re-educated on documentation in resident charts on changes in condition. 3. Nurses will be re-educated on resident assessments as it relates to changes in condition. 4. Nurses will be re-educated to notify physician by telephone when receiving abnormal diagnostic results, and documenting response in medical record, and follow-through with orders when indicated. 5. Nursing administrative staff will review resident charts to ensure previously ordered diagnostic tests have been followed-through with MD notification. 6.Nurses will be re-educated on process of ordering diagnostic testing to included orders, MD & family notification, documentation, and following-up with results or inability to obtain testing. 7. Educate nurses on physical assessments. 8. Educate nurses to follow-up at beginning of shift on all pending diagnostic tests from pervious shift, and calling if they haven ' t received results. Target completion date will be ,[DATE]/ or prior to the start of the next scheduled shift. (sic) On [DATE] the surveyors confirmed the POR was implemented sufficiently to remove the Immediate Jeopardy by: Two RNs, 3 LVNs, and 1 LVN (ADON) were in-serviced on MD/family notification of change in resident condition, documentation in resident charts and change in condition, resident assessments, notifying physicians by phone of abnormal diagnostic results, and following up on results. Ten residents' charts were reviewed for ordered, pending diagnostic testing, and MD notification of results. All were correct and complete. On [DATE] at 2:20 p.m., the administrator, corporate nurse, DON, and ADON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The resident roster dated [DATE] indicated there were 91 residents in the facility.

Based on observation, interview, and record review, the facility failed to develop and implement their written policies and procedures to prohibit neglect for 2 of10 residents reviewed for neglect. (Residents #1 and #3) 1. Resident #1 had a significant change in his condition and experienced respiratory distress for over a week. The facility did not recognize progressive symptoms or assess Resident #1 when he had a decline in condition and experienced respiratory distress. The facility did not consult with the physician regarding the resident ' s continuous decline and of an abnormal chest x-ray. Resident #1 continued to decline and died 5 days after his condition began to deteriorate and the abnormal x-ray was obtained. 2. The facility did not: * ensure Resident #3 did not receive medications, to which she was allergic. She received 5 doses. * perform blood sugar checks as ordered by the physician. * perform neurological assessments as ordered following a fall. Resident #3 died 2 hours after the reported fall. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 91 residents at risk for serious injury or possible death. Findings included: The Abuse/Neglect Policy revised [DATE], indicated neglect was the failure to provide goods and services necessary to avoid physical harm. Facility supervisors would immediately correct and intervene in reported or identified situations in which neglect was at risk for occurring. Immediate Jeopardy was a situation in which the provider ' s non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death of a resident. 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #1's baseline respirations were 20 breaths a minute and oxygen saturation level was 97%. According to the website, http://www.medguidance.com/thread/Oxygen-Saturation-Levels, accessed [DATE], oxygen saturation levels, they are referring to the extent of haemoglobin that is saturated with oxygen and .normal oxygen saturation level is between 95% to 100% . Nursing notes dated [DATE] at 3:00 p.m., indicated Resident #1 wandered out the door and was found walking on a sidewalk by the facility. Resident #1 was escorted back in the building and assisted to his wheelchair. The notes indicated Resident #1 said he was walking out of the facility. Nursing notes dated [DATE] at 8:29 a.m., indicated Resident #1 ambulated down the hall and attempted to elope out the back door. He was assisted back to his wheelchair by staff. Resident #1 said he was going home. Nursing notes dated [DATE] at 4:05 a.m., indicated Resident #1's oxygen saturation level was 96% (his baseline was 97%). Nursing notes dated [DATE] at 9:22 a.m., indicated Resident #1 demanded staff to push him down the hall in his wheelchair to be let out of the facility. [MEDICATION NAME] (anti-anxiety medication) was administered to Resident #1. An oxygen saturation level log for Resident #1 indicated his oxygen saturation levels included the following: (Baseline 97%) *[DATE] - 93%, *[DATE] - 94%. The log did not indicate if the resident's respiratory status was assessed or if the physician was consulted. Nursing notes dated [DATE] at 1:45 p.m., indicated Resident #1 said he called for assistance for a long time, but nobody came to his room. He said he needed to go to the bathroom. Resident #1 was assisted back to his room and he was getting short of breath. Oxygen was placed on the resident and he received a breathing treatment with good results. Nursing notes dated [DATE] at 7:00 p.m., indicated Resident #1 was not able to support himself in a seated position. Resident #1 was becoming increasingly lethargic and agitated. He developed a productive cough and was short of breath at rest. The notes did not indicate if the nurse assessed the resident or consulted with the physician. Nursing notes dated [DATE] at 6:40 p.m., indicated Resident #1 had labored respirations, he was short of breath, and was mouth breathing. He did not eat breakfast or lunch. The notes did not indicate if the physician was consulted or if the nurse applied oxygen for respiratory support. Nursing notes dated [DATE] at 1:57 p.m., indicated Resident #1 was noted to have difficulty breathing, was coughing, and was wheezing. The notes did not indicate if the physician was consulted or if the nurse applied oxygen for respiratory support or any other intervention. Nursing notes dated [DATE] at 2:01 p.m., indicated the on call doctor was notified of Resident #1's condition and a STAT (immediate) chest x-ray was ordered. During a telephone interview on [DATE] at 9:01 a.m., LVN A said she worked on [DATE] and was covering for LVN B (who was responsible for Resident #1) while LVN B was at lunch. She said Resident #1 was having difficulty breathing and did not look good. She said she called the on call doctor who ordered a chest x-ray. She said there was no follow up on the x-ray even though she told LVN B that she ordered the chest x-ray. LVN A said when she left on Sunday, she did not come back until the next Saturday and Resident #1 was deceased when she returned the following Saturday ([DATE]). During an interview on [DATE] at 11:30 a.m., LVN C said on [DATE], she went into Resident #1's room with LVN A. She said Resident #1 was pale and was having difficulty breathing. She said she thought he had a change of condition and that was why LVN A ordered the chest x-ray. LVN C thought Resident #1 would be sent out to the hospital for further evaluation. She said she did not know if anything else was done for Resident #1. During an interview on [DATE] at 2:57 p.m., LVN B said LVN A covered her shift while she went to lunch and ordered a chest x-ray for Resident #1. She said when she came back from lunch, LVN A told her she needed to check on Resident #1 and follow up on the chest x-ray. She said she went into Resident #1's room and he was breathing like he always did. LVN B said she did not assess Resident #1. She said normally x-ray results were faxed, but she did not receive Resident #1's chest x-ray results and she did not call the x-ray company to get the results. She said she told the oncoming nurse that the resident had a chest x-ray and wrote it on the 24 hour report for [DATE], but it was not transferred to the 24 hour report for [DATE]. A STAT (immediate) chest x-ray result dated [DATE] for Resident #1 indicated he had pneumonia in both of his lungs and the word ALERT was written across the results. During a telephone interview on [DATE] at 1:20 p.m., the on call doctor's nurse said the facility did not call the on call doctor to notify him of the x-ray results. A 24-hour report sheet dated [DATE] indicated Resident #1 received a chest x-ray and was short of breath. The [DATE] 24-hour report did not contain any other information regarding Resident #1. During an interview on [DATE] at 1:30 p.m., the DON said Resident #1's physician was not notified of results of the chest x-ray. She said normal procedure would be to fax the doctor with the results, but the fax machine was not working properly on [DATE]. She said LVN B told her Resident #1 was agitated on [DATE]. She said she was not aware that Resident #1 had pneumonia. Nursing notes dated [DATE] at 11:20 a.m., indicated the NP was notified of Resident #1's declining strength and poor food intake. The NP said to make him an appointment with his primary doctor to talk about hospice. The notes did not indicate if the NP was notified of the resident's x-ray results. Nursing notes dated [DATE] at 5:52 a.m., indicated Resident #1 occasionally yelled out for help. Resident #1 became easily short of breath and had increased weakness with mobility. Nursing notes dated [DATE] at 10:55 p.m., indicated Resident #1 continued to decline. Resident #1 did not eat or drink fluids the entire day. His oxygen saturation levels were 88%-90% (his baseline was 97%). Nursing notes dated [DATE] at 5:40 a.m., indicated Resident #1 continued to decline and his skin was pale and warm. Resident #1's respirations were shallow and he was short of breath. Resident #1's oxygen saturation levels remained between 86%-90% (his baseline was 97%). He required maximum assistance of 2 staff with ADLs and mobility. Nursing notes dated [DATE] at 7:10 a.m., indicated Resident #1 was not doing good at all. Resident #1's oxygen saturation was 89% and his respirations were 32 breaths a minute, and were rapid and shallow. Resident #1 moaned a little to a sternal rub (his baseline was 20 breaths a minute and 97% oxygen saturation level). Nursing notes dated [DATE] at 9:46 a.m., indicated Resident #1 received a new order for [MEDICATION NAME] for comfort measures. Nursing notes dated [DATE] at 2:30 p.m., indicated Resident #1 was lying in bed with his eyes and mouth open, and responded to sternal rub only. Resident #1's oxygen saturation level was 91% (his baseline was 97%) and [MEDICATION NAME] was given to Resident #1 for comfort measures. An oxygen saturation level log for Resident #1 indicated his oxygen saturation levels from [DATE] through [DATE] and [DATE]- [DATE] were between 95%-98%. Nursing notes dated [DATE] at 12:20 a.m., indicated Resident #1 was grimacing and had shortness of breath with shallow respirations. Resident #1's oxygen saturation level was 78% (his baseline was 97%) and his skin was hot to touch. He had occasional apnea episodes (not breathing) [MEDICATION NAME] up to 10 seconds. [MEDICATION NAME] was administered to Resident #1 for comfort. Nursing notes dated [DATE] at 1:00 a.m., indicated Resident #1 was resting quietly with shallow respirations. Resident #1 had mottling to all 4 extremities and his skin was hot to touch. Resident #1 was unresponsive to touch or verbal stimuli. Nursing notes dated [DATE] at 1:45 a.m., indicated Resident #1 was pronounced dead by an RN. During an interview on [DATE] at 2:10 p.m., CNA D said Resident #1 had a rapid decline in the last week of his life. She said his breathing and his appearance were dramatically worse. During a telephone interview on [DATE] at 11:17 a.m., Resident #1's primary physician's nurse said they were not notified of Resident #1's pneumonia. She said the only communication they received about Resident #1 was a fax on [DATE] about the resident expiring. During a telephone interview on [DATE] at 12:33 p.m., the NP said she did not know Resident #1 had expired. She said the facility called her the previous week to notify her of Resident #1's decline in health, but the facility did not notify her that he had pneumonia. She said if the facility would have notified her of Resident #1's pneumonia, she would have ordered him an antibiotic. During an interview on [DATE] at 3:45 p.m., the administrator said he knew Resident #1 had pneumonia, but did not know any more details. During an interview on [DATE] at 3:50 p.m., the corporate nurse said she knew a chest x-ray was ordered for Resident #1 and the physician was not notified of the results of the chest x-ray. 2. Physician orders [REDACTED].#3, [AGE] years old, was admitted on [DATE] and was a Do Not Resuscitate status (DNR). Her [DIAGNOSES REDACTED]. The final orders also indicated she expired in the facility on [DATE]. Nursing notes dated [DATE] at 11:11 a.m., indicated Resident #3 had a reddened, open area to her left lower leg and the doctor was notified. A new order for the antibiotic [MEDICATION NAME] was received. Physician orders [REDACTED].#3 was ordered [MEDICATION NAME] (antibiotic) 300 mg to be given by mouth three times a day for a wound infection. A computerized MAR for [DATE] indicated Resident #3 was allergic to [MEDICATION NAME], fish, iodine, [MEDICATION NAME], and [MEDICATION NAME]. Nursing notes dated [DATE] at 2:00 p.m., indicated Resident #3 was ordered [MEDICATION NAME] 300 mg, orally three times a day. The notes indicated prior to administration of the [MEDICATION NAME], Resident #3 said intravenous [MEDICATION NAME] made her skin itch. The initial dose of [MEDICATION NAME] was given. A hand-written MAR for [DATE], that included the order for [MEDICATION NAME] 300 mg, three times a day, did not include Resident #3's allergies [REDACTED]. An incident report dated [DATE] indicated at 5:30 a.m., Resident #3 attempted to get out of bed to use the bathroom, lost her balance, and sat on the floor. The incident report indicated Resident #3 did not have any injuries; her vital signs were within normal limits. A neurological record dated [DATE] indicated 30 minute neurological checks were initiated at 6:00 a.m., Vital signs were documented as the same as the incident report. The 6:00 a.m. neurological check indicated Resident #3 was drowsy, opened her eyes to speech, and she flexed all four of her extremities abnormally. No further neurological checks were documented. A MAR for [DATE] indicated Resident #3's blood sugar was to be checked at 6:30 a.m. There was no entry for Resident #3's blood sugar on [DATE]. Nursing notes dated [DATE] at 7:15 a.m., indicated Resident #3 was lying on her bed with her eyes closed. Resident #3's lips were purple and mottling was noted to her right arm and hand. Resident #3 was unresponsive with no blood pressure and no pulse. The Changes in Resident Condition Policy revised [DATE], indicated the resident, the attending physician, and family member would be notified when changes in condition occurred. Communication with the interdisciplinary team and caregivers was also important to ensure that consistency and continuity were maintained. Changes in condition were communicated from shift to shift though the 24 hour report. The administrator was notified on [DATE] at 4:19 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 7:18 p.m. and included: 1. Nurses will be re-educated on MD/Family notification of change in resident condition. 2. Nurses will be re-educated on documentation in resident charts on changes in condition. 3. Nurses will be re-educated on resident assessments as it relates to changes in condition. 4. Nurses will be re-educated to notify physician by telephone when receiving abnormal diagnostic results, and documenting response in medical record, and follow-through with orders when indicated. 5. Nursing administrative staff will review resident charts to ensure previously ordered diagnostic tests have been followed-through with MD notification. 6.Nurses will be re-educated on process of ordering diagnostic testing to included orders, MD & family notification, documentation, and following-up with results or inability to obtain testing. 7. Educate nurses on physical assessments. 8. Educate nurses to follow-up at beginning of shift on all pending diagnostic tests from pervious shift, and calling if they haven ' t received results. Target completion date will be ,[DATE]/ or prior to the start of the next scheduled shift. (sic) On [DATE] the surveyors confirmed the POR was implemented sufficiently to remove the Immediate Jeopardy by: Two RNs, 3 LVNs, and 1 LVN (ADON) were in-serviced on MD/family notification of change in resident condition, documentation in resident charts and change in condition, resident assessments, notifying physicians by phone of abnormal diagnostic results, and following up on results. Ten residents' charts were reviewed for ordered, pending diagnostic testing, and MD notification of results. All were correct and complete. On [DATE] at 2:20 p.m., the administrator, corporate nurse, DON, and ADON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The resident roster dated [DATE] indicated there were 91 residents in the facility.

Based on observation, interview, and record review, the facility failed to provide nutritional supplements to prevent weight loss for 4 of 11 residents sampled for weight loss. (Resident #s 1, 10, 11 and 12) Resident #1 had a 13.4% weight loss of 22.6 pounds from 11/10/11 to 02/03/12 and low protein levels. For over 2 months, Resident #1 was to have received a fortified food item at lunch and dinner. She did not receive a fortified food item for 3 of 3 meals observed and her tray card did not note she was to receive a fortified food item. Resident #12 experienced continued weight loss and had a low protein level. He had a 13.8% weight loss of 23 pounds in six months and an 11.1% weight loss of 18 pounds in three months. He did not receive a Magic Cup (a high protein dairy supplement) and/or fortified food item as ordered. Resident #10 returned from the hospital with a nutritional compromise. He did not receive a Magic Cup and/or fortified food item as ordered. Resident #11 was nutritionally compromised and did not receive a Magic Cup at 1 of 3 meals observed. This failure contributed to Resident #s 1 and 12's severe weight loss and could place 29 residents who were to receive fortified foods at risk for nutritional compromise. Findings included: 1. Physician orders [REDACTED]. Resident #1 was to receive a diet with reduced concentrated sweets with a fortified food item at lunch and dinner. The start date on the diet was 12/7/11. The Medical Nutritional Therapy Review form dated 10/25/11 indicated Resident #1's usual weight was 165 pounds. Hospital laboratory results dated [DATE] noted Resident #1 had a low [MEDICATION NAME] level of 88 (reference range 176-360). The website <http://www.labtestsonline.org/understanding>, accessed 02/09/12, noted, "[MEDICATION NAME] test ordered ....to evaluate nutritional status" and "diagnose protein-calorie [MEDICAL CONDITION]." The care plan dated 12/5/11 indicated Resident #1 had unplanned weight loss. The care plan included interventions dated 12/7/11 to provide fortified food items with lunch and dinner. The care plan goal was for Resident #1 to receive adequate nutrition and fluid intake. A change of condition form dated 12/05/11 indicated Resident #1 had a decrease in weight of 5.34% in one month and the intervention was to provide a fortified food item with lunch and dinner. A change of condition form dated 12/07/11 indicated the resident's weight was 159.6 pounds. A dietary progress note for Resident #1 dated 12/12/11 by the RD noted to continue with ordered diet regimen to stabilize weight. The weight log from October 2011 through February 2012 noted the following weights for Resident #1: 11/10/11 - 168.6 pounds 12/26/11 - 152 pounds 01/05/12 - 148 pounds 02/03/12 - 146 pounds A dietary progress note for Resident #1 dated 01/11/12 by the RD noted, weight of 148 pounds and "weight decrease trend slowed past 3-4 weeks" and to continue with supplemental calories. The most recent MDS dated [DATE] indicated Resident #1 had no cognitive impairment, was dependent on staff for ADLs, and required set up assistance with meals. During an observation and interview on 02/06/12 at 5:40 p.m., Resident #1 received her meal tray and there was no item marked fortified food. MA I said the dietary department never marked the fortified foods. She said she did not know which food item was the fortified food for the evening meal. The undated tray card did not indicate Resident #1 was to receive a fortified food item. During an interview on 02/06/12 at 6:05 p.m., the FSS said there was no fortified food item available for this meal. During an observation on 02/07/12 at 12:55 p.m., Resident #1 received her meal tray and there was no item marked fortified food. There was no soup on the tray. The undated tray card did not indicate Resident #1 was to receive a fortified food item. During an interview on 02/07/12 at 1:07 p.m., the FSS said the fortified food item was a bowl of soup. During an observation on 02/08/12 at 12:20 p.m., Resident #1 received her meal tray and there was no item marked fortified food. There was no shake on the tray. The undated tray card did not indicate Resident #1 was to receive a fortified food item. During an interview on 02/08/12 at 12:35 p.m., the RD said the fortified food item was a "dreamsicle shake." During an interview on 02/08/12 at 7:00 p.m., the RD said the facility did not have any residents with significant weight loss. The CMS 672 dated 02/06/12 indicated 12 residents with significant weight loss/gain. An undated facility typed list received on 02/06/12 indicated 9 residents with weight loss. 2. Physician orders [REDACTED]. Resident #12 was to receive a regular diet with fortified foods for lunch and dinner, a Magic Cup for lunch and whole milk with meals. The start date on the diet was 08/28/09. On 01/31/12, the diet order changed to a pureed diet with fortified foods for lunch and dinner, a Magic Cup for lunch and whole milk with meals. The Medical Nutritional Therapy Review dated 11/22/10 indicated Resident #12's usual weight was "170s." The weight log from February 2011 through February 2012 noted the following weights for Resident #12: 08/05/11 - 167 pounds 11/18/11 - 162 pounds 02/03/12 - 144 pounds. laboratory results dated [DATE] noted Resident #12's [MEDICATION NAME] was low at 10.7 (reference range 18.0-45.0). The website <http://www.labtestsonline.org/understanding>, accessed 02/09/12, noted, "[MEDICATION NAME] test ordered ....to evaluate nutritional status" and "diagnose protein-calorie [MEDICAL CONDITION]." The most recent MDS dated [DATE] indicated Resident #12 was cognitively impaired, was dependent on staff for ADLs, and required extensive assistance with meals. A care plan dated 02/06/12 indicated Resident #12 had unplanned weight loss. The care plan included interventions dated 01/31/12 to provide a fortified food item with lunch and dinner. The care plan goal was for Resident #12 to receive adequate nutrition and fluid intake. During an interview on 02/08/12 at 12:35 p.m., the RD said the fortified food item for lunch was a "dreamsicle shake." During an observation on 02/08/12 at 1:05 p.m., Resident #12 was in bed with his meal tray in front of him. There was nothing to drink on his tray and there was no Magic Cup or fortified food item (dreamsicle shake). The undated diet card indicated Resident #12 was to have water and whole milk with meals. There was no indication on the diet card of a physician ordered fortified food item for lunch. During an observation on 02/08/12 at 1:17 p.m., Resident #12 had eaten a few bites of his meal and drank 100% of his tea. During an interview on 02/08/12 at 7:00 p.m., the RD said the facility did not have any residents with significant weight loss. 3. Physician orders [REDACTED]. He was readmitted [DATE] from the hospital after having a stroke with recently sustained weight loss. He had no teeth. His orders indicated he was to receive pureed, large portions with fortified foods at all meals. He was to receive 8 oz. of whole milk at each meal and a Magic Cup at lunch and supper. The MDS dated [DATE] indicated Resident #10 was cognitively impaired and required supervision of 1 person with eating. During an observation on 2/6/11 at 5:50 p.m., Resident #10 did not receive a Magic Cup or a fortified food product. During an observation on 2/7/12 at 12:45 p.m., Resident #10 received a pureed diet plate. He did not receive cream of mushroom soup which was the fortified food prepared for lunch. During an interview on 02/07/12 at 1:07 p.m., the FSS said the fortified food item was a bowl of soup. During an observation on 2/8/12 at 12:45 p.m., Resident #10 received a puree diet plate of fried chicken, macaroni and cheese, and green beans. He did not receive a Magic Cup. 4. Physician orders [REDACTED]. His orders indicated he was to receive 8 oz. of whole milk at every meal and a Magic Cup at supper. The MDS dated [DATE] indicated Resident #11 was cognitively impaired and required extensive assistance of 1 person with eating. During an observation on 2/6/12 at 6:05 p.m., Resident #11 received a regular diet plate. He did not receive a Magic Cup. A diet roster dated 2/6/12 indicated 29 residents received fortified foods.