Every finding on record at Parkwood Village

Based on interviews and record review, the facility failed to ensure the transfer or discharge is documented in the resident's medical record by the attending physician for 4 of 8 residents (Resident #2, Resident #5, Resident #6, and Resident #8) reviewed for discharge planning.The facility failed to have the physician document the basis for transfer or discharge facility for Resident #2, Resident #5, Resident #6, and Resident #8 and the specific needs that could not be met at the facility.This failure could result in inappropriate discharges or transfers, causing physical or mental harm to the residents.Findings included:Record review of Resident #2's Provider Progress Note dated 07/10/2026 9:00am revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Alcohol dependence with withdrawal, Alcoholic Hepatitis (liver damage due to alcohol abuse), Hypomagnesemia (low magnesium levels), and Hypokalemia (low potassium levels).A review of Resident #2's progress notes dated 07/12/2026 at 2:36 pm showed that Resident #2 was discharged to an alcohol treatment facility. The Interdisciplinary Discharge summary dated [DATE] 8:42 pm failed to include the basis for the discharge, what need(s) couldn't be met at the facility, the attempts to meet the resident's needs, and the service available at the receiving facility to meet the resident's need(s).Record review of Resident #5's MDS assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Spondylosis (arthritis of the spine), Dementia (condition that affects memory), Protein-Calorie Malnutrition (condition that where the body does not get enough nutrients), and Osteoporosis (brittle bones).A review of Resident #5's progress note dated 07/13/2026 at 10:30 am revealed she was discharged to a memory care facility. The Interdisciplinary Discharge summary dated [DATE] 8:40 pm failed to include the basis for the discharge, what need(s) couldn't be met at the facility, the attempts to meet the resident's needs, and the service available at the receiving facility to meet the resident's need(s).Record review of Resident #6's MDS assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Traumatic ischemia of the muscle (leg freezing), Depression, Mood Disorder, and Weakness.A review of Resident #6's progress note dated 07/25/2026 at 3:15 pm revealed she was discharged to another inpatient rehabilitation facility. The Interdisciplinary Discharge summary dated [DATE] 8:48 am failed to include the basis for the discharge, what need(s) couldn't be met at the facility, the attempts to meet the resident's needs, and the service available at the receiving facility to meet the resident's need(s).Record review of Resident #8's MDS assessment dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Orthostatic Hypotension (drop in blood pressure upon standing), Depression, Sleep Apnea (sleep disorder that causes breathing to start and stop at night), Syncope (fainting), anxiety disorder, and Mild Cognitive Impairment.A review of Resident #8's progress note dated 07/10/2026 at 3:07 pm revealed she was discharged home with home health care. The Interdisciplinary Discharge summary dated [DATE] 10:09 am failed to include the basis for the discharge.An interview with the DON on 08/19/2026 at 2:37 pm revealed that the physician has a place to sign on the discharge summaries, she said she types the physician's name and signs her name to lock the discharge summary. She said she was aware that they were not signing them.An interview with the Administrator on 08/19/2026 at 2:56 pm revealed she was unaware that the physician was required to sign discharge summaries.In a record review of the facility's Transfer or Discharge, Resident-Initiated Policy dated October 2022, revealed: Required Notices - For resident-initiated transfers or discharges, sending a copy of the resident's notice of intent to leave the facility to the ombudsman is not required.For resident-initiated discharges, the medical record contains documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care (per F660, Discharge Planning Process, and F661, Discharge Summary).In a record review of the facility's Transfer or Discharge, Facility-Initiated Policy dated October 2022, revealed: Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge is documented in the resident's clinical record by the resident's attending physician:The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; orThe transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.

Based on interviews and record review, the facility failed to complete discharge summaries and provide them to 4 of 8 (Resident #2, Resident #5, Resident #6, and Resident #8) at the time of discharge, and failed to notify the Office of the State LTC Ombudsman for 8 of 8 residents (Resident #1, Resident #2, Resident #3, and Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) reviewed for discharge planning.The facility failed to have the physician include a recapitulation of the resident's stay in the medical records of Resident #2, Resident #5, Resident #6, and Resident #8.The facility failed to send a copy of the notice of discharge to a representative of the Office of the State LTC Ombudsman for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8.The facility failed to provide a discharge summary at the time of discharge for Resident #2, Resident #5, Resident #6, and Resident #8.These failures could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. Findings:1. Record review of Resident #1's MDS assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include spinal fracture, Cognitive communication deficit (condition that affects memory), Vitamin D Deficiency, Anxiety, and Depression.A review of Resident #1's progress notes dated 07/16/2026 at 7:54 pm showed that Resident #1 left the facility Against Medical Advice (AMA)to home with home health care. There was no evidence that a transfer or discharge notice was provided to Resident #1 or to the State LTC Ombudsman.2. Record review of Resident #2's Provider Progress Noted dated 07/10/2026 9:00 am revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Alcohol dependence with withdrawal, Alcoholic Hepatitis (liver damage due to alcohol abuse), Hypomagnesemia (low magnesium levels), and Hypokalemia (low potassium levels).A review of Resident #2's progress notes dated 07/12/2026 at 2:36 pm showed that Resident #2 was discharged to an alcohol treatment facility. There is no evidence that a transfer or discharge notice was provided to Resident #2 or to the State LTC Ombudsman. Additionally, an Interdisciplinary Discharge summary dated [DATE] at 8:42 pm showed no recapitulation of the resident's stay, and no evidence that the discharge summary was given to Resident #2 upon discharge.3. Record review of Resident #3's MDS assessment dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] at 4:10 pm. Her diagnoses include Low back pain, Scoliosis (curvature of the spine), and High Blood Pressure.A review of Resident #3's progress note dated 07/10/2026 at 9:35 am revealed the resident was discharged from the facility AMA to an unknown location. There was no evidence that a transfer or discharge notice was provided to Resident #3 or to the State LTC Ombudsman.4. Record review of Resident #4's MDS revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses include Leg fracture, Diabetes (inability to control sugar levels in the blood), and High Blood Pressure.A review of Resident #4's progress note dated 07/14/2026 at 10:55 am revealed the resident had an unplanned discharge from the facility to home. There was no evidence that a transfer or discharge notice was given to Resident #4 or to the State LTC Ombudsman. 5. Record review of Resident #5's MDS revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Spondylosis (arthritis of the spine), Dementia (condition that affects memory), Protein-Calorie Malnutrition (condition that where the body does not get enough nutrients), and Osteoporosis (brittle bones).A review of Resident #5's progress note dated 07/13/2026 at 10:30 am revealed she was discharged from the facility to a memory care center. There was no evidence that a transfer or discharge notice was given to the State LTC Ombudsman. Additionally, an Interdisciplinary Discharge summary dated [DATE] at 8:47 pm showed no recapitulation of the resident's stay.6. Record review of Resident #6's MDS assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Traumatic ischemia of the muscle (leg freezing), Depression, Mood Disorder, and Weakness.A review of Resident #6's progress noted dated 07/25/2026 at 3:15 pm revealed she was discharged to another facility. There is no evidence that a transfer or discharge notice was given to Resident #6 or the State LTC Ombudsman. Additionally, an Interdisciplinary Discharge summary dated [DATE] at 8:48 am showed no recapitulation of the resident's stay, and no evidence that the discharge summary was given to Resident #6 upon discharge.7. Record review of Resident #7's MDS assessment dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Cerebral Infarction (Stroke), Aphasia (inability to communicate due to stroke), Occlusion of Bilateral Carotid Arteries (closure of arteries on both sides of the neck leading to the brain), and Neck Fracture.A review of Resident #7's progress note dated 07/30/2026 at 9:40 pm revealed she was discharged to an acute care hospital. There was no evidence that a transfer or discharge notice was given to Resident #7 or the State LTC Ombudsman.8. Record review of Resident #8's MDS assessment dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Orthostatic Hypotension (drop in blood pressure upon standing), Depression, Sleep Apnea (sleep disorder that causes breathing to start and stop at night), Syncope (fainting), anxiety disorder, and Mild Cognitive Impairment (condition that affects memory).A review of Resident #8's progress note dated 07/10/2026 at 3:07 pm revealed she was discharged to home with home health care. There was no evidence that a transfer or discharge notice was given to Resident #8 or the State LTC Ombudsman. Additionally, an Interdisciplinary Discharge summary dated [DATE] at 10:09 am showed no recapitulation of the resident's stay, and no evidence that the discharge summary was given to Resident #8 upon discharge.An interview with the DON on 08/19/2026 at 2:37 pm revealed that she was unaware that the State Ombudsman needed to be notified of discharges.An interview with the Administrator dated 08/19/2026 at 2:56 pm revealed that she was aware that the Ombudsman was not being notified but did not know the impact on residents due to failing to notify the Ombudsman.In a record review of the facility's Transfer or Discharge, Resident-Initiated Policy dated October 2022, revealed: Required Notices - For resident-initiated transfers or discharges, sending a copy of the resident's notice of intent to leave the facility to the ombudsman is not required.For resident-initiated discharges, the medical record contains documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care (per F660, Discharge Planning Process, and F661, Discharge Summary).In a record review of the facility's Transfer or Discharge, Facility-Initiated Policy dated October 2022, revealed: A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). Should the resident be transferred or discharged .the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's attending physician. When a resident is transferred or discharged from the facility, the following information is documented in the medical record: .a summary of the resident's overall medical, physical, and mental condition.

Based on observations, interviews, and recorded reviews, the facility failed to ensure that residents received the necessary care and services to attain or maintain the highest practicable mental and psychosocial well-being consistent with the resident comprehensive assessment and plan of care for one resident (Resident#1) of 10 residents reviewed for quality of life. The facility failed to ensure Resident#1 received prompt assistance needed to maintain comfort ,dignity, and safety. This failure could put the residents at risk for unmet needs, falls, Incontinence, skin breakdown, and emotional distress.Findings included: Record review of Resident #1's MDS assessment, dated 06/01/2026, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 15, indicating she was cognitively intact. Her diagnoses included arthritis. Record review of Resident #1's care plan initiated: 06/28/2026 reflected: [Resident#1] has an ADL self-care performance deficit r/t Activity Intolerance, Disease Process, Fatigue. Interventions included: TOILET USE: Requires extensive assist of two staff due to arthritis TRANSFER: Requires extensive assist of two staff due to arthritis Encourage use of bell to call for assistance. Observation on 07/13/2026 at 10:01am revealed Resident#1's call light was on. More than three Staff members were observed walking by the residents' room but none of the staff members were observed going into Resident#1s' room. During an interview on 07/13/2026 at 10:03am with Resident#1 she stated that she had activated her call light 15 mins prior to the surveyor entering her room. She stated that no staff member had checked what she needed. She stated that she needed someone to assist with getting her ready for physical therapy. Observation on 07/13/2026 at 10:29am revealed Resident#1's call light was still on, 29 minutes since the initial interaction with Resident #1. More than three Staff members continued to be observed walking by the resident's room. Resident #1 stated that no staff had gone in her room to answer her call light. The ADON entered the resident's room to answer her call light. During an interview on 07/13/2026 at 10:30am, the ADON stated that all staff members were responsible for answering the call lights, and if necessary, notifying the nurses or CNA. She stated that 29 minutes was too long for a resident to wait for staff to go in and check what she needed. She stated the risk was that the resident could be in an emergent situation or could have had a change in condition. During an interview on 07/13/2026 at 12:33pm with CNA A revealed she was Resident #1's CNA. She stated that she was giving another resident a shower when Resident#1's call light came on. She stated that all staff were responsible for answering the call lights. She stated that a prolonged delay in answering residents' call lights could lead to injury because the residents would try to get out of bed by themselves, or they would get emotionally stressed out. She stated she had been in-serviced on call light response. During an interview on 07/13/2026 at 2:43pm with the DON, she stated that she realized call light response was a problem when she was hired three months ago, and she had been working with the staff on call light response. She stated that her expectation was that all staff should answer call lights as soon as they saw the call light then notify the nurse or CNA of the residents' needs. She stated that 29 mins was too long for a resident to wait for staff to go in and check what she needed. She stated the risk of delayed call light response was residents getting hurt in attempts to do for themselves. She stated that staff had been in-serviced on call light response. Record review of the Facility's Policy titled Answering the Call Light Level revised September 2022 revealed: PurposeThe purpose of this procedure is to ensure timely responses to the residents' requests and needs. Steps in the Procedure1. Answer the resident call system immediately.2. If assistance is needed when you enter the room, summon help by using the call signal.

Based on observation and interviews, the facility failed to ensure the resident environment remained free of accident hazards as possible for 1 (200 hall) out of 3 hallways reviewed for quality of care. The facility failed to ensure that the mechanical lift on 200 hall was locked and secured when not in use. This failure could place residents at risk of falls and/or injuries. Findings Included: Observation on 07/13/26 at 10:17 am of the 200 hall revealed an unlocked and unsecured mechanical lift parked where residents were observed wheeling themselves up and down the hallway. During an interview on 07/13/26 at 10:25 am with CNA B revealed that mechanical lifts should always be locked and stored away from high traffic areas where residents could access them and get hurt. She stated she had been in-serviced on mechanical lifts to include storage. During an interview on 07/13/26 at 10:28 am, LVN C stated that mechanical lifts should always be locked when in the communal areas, such as the hallways, and when not being used. LVN C stated that mechanical lifts were stored on the right side of the hallway away from residents. She stated that the failure to lock mechanical lifts could cause accidents that could injure residents including getting fractures that could lead to hospitalization. During an interview on 07/13/26 at 11:05 am with CNA A, she stated mechanical lifts must always be locked and the red button activated to make sure there were no moving parts. She stated the risk was that a resident might attempt to support themselves and get injuries that could be serious and lead to hospitalizations. She stated she had been in-serviced on mechanical lifts to include securing and storing. During an interview on 07/13/26 at 3:15pm with the DON, she stated that her expectation was that all mechanical lifts should be locked when they were not in use. The DON stated that all staff had been educated on locking mechanical lifts. She stated that all Hoyer lifts were to be stored on one side of the building and locked when not in use. She stated that she would re-educate staff with in-service training on mechanical lifts and mechanical lift storage and safety. She stated that there was a risk to residents if they attempted to pull themselves up using an unlocked and unsecured mechanical lift, which could cause injuries.

Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 2 residents (Resident #4) reviewed for abuse and neglect. The facility did not thoroughly investigate an incident in which Resident #4 made a grievance that a staff member pinched her. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.The findings were: A record review of Resident #4's Nursing Home PPS MDS, dated [DATE], reflected the Resident #4 was an [AGE] year old female who was admitted to the facility on [DATE]. Resident #4 had an active diagnosis of Cerebral Infraction. Resident #4's had a BIMS score of 08, which indicated moderate cognitive impairment. A record review of Resident #4's Care Plan, dated 05/15/2026, reflected Resident #4 has two bruises to the left forearm. Goal to be free from skin tears and interventions included monitor/document location, size and treatment of bruise, keep skin clean and dry, inform staff of causative factors and measures to prevent skin issues, and encourage good nutrition in order to promote healthier skin. A record review of provider investigation report revealed on 05/15/2026 Resident #4 reported to the assistant director of nursing that she believed that a staff member had pinched her when they provided care. The provider investigation report revealed no alleged perpetrator was named, no documentation of who was contacted regarding alleged abuse allegation, no documentation of witness statements were provided. The provider investigation report reflected safe surveys were completed and abuse and neglect in-services were provided. Durning an interview on 05/29/26 at 9:25 a.m., the ADM revealed he was notified on Friday, 05/15/26 at 5:15 p.m., that there was an alleged allegation of abuse. The ADM stated that he had returned to the building on 05/15/2026 at 5:30 p.m. and interviewed Resident #4. The ADM stated that Resident #4 was unable to recall a specific date or time of incident only that it was Wednesday, Thursday or Friday night. The ADM stated Resident #4 was not able to provide a description of an alleged perpetrator. The ADM stated Resident #4 was unable to state what color scrubs the staff member wore. He stated that nurses wore burgundy and aides wore blue. The ADM stated Resident #4 showed him two marks on her arms and he asked Resident #4 was she pinched once or twice and Resident #4 responded once. The ADM stated he asked Resident #4 if she felt safe and Resident #4 replied yes she did. The ADM stated he asked Resident #4 if she was in pain and Resident #4 responded that she was not in pain. The ADM stated that he called the DON at or around 9:45 p.m. and instructed her to call staff who worked the night shift for 05/13/26, 05/14/26 and 05/15/26 to see if they were aware of what happened to Resident #4, start in-services and conduct safe surveys. During an interview on 05/29/2026 at 10:37 a.m., the DON revealed that she was notified by the ADM via phone that there was an alleged allegation of abuse. The DON stated that she had arrived at the facility the morning of Saturday, 05/16/26 and went to ensure Resident #4 felt safe and if she could provide any additional details. The DON stated Resident #4 revealed to her that she felt safe, but Resident #4 could not describe an alleged perpetrator, could not state what day it happened, could not provide if staff provided care or happened in bed. The DON stated she then conducted safe surveys of the residents to ensure everyone felt safe. The DON stated that there were no negative findings from safe surveys. The DON stated she called staff that worked that Wednesday, Thursday and Friday night. She stated that no staff knew anything about Resident #4 bruises. The DON stated Resident #4 would often transfer herself to her bedside commode. The DON stated that the bedside commode had a lid and believed that it may have caused Resident #4 to have the two bruises. The DON stated Resident #4 required one person assist but often had to be reeducated to use call light or ask for assistance. Attempted phone interview with RN A on 05/29/2026 at 11:03 a.m., no answer and no returned call back prior to exit of the facility. Attempted phone interview with CNA B on 05/29/2026 at 11:06 a.m., no answer and no returned call back prior to exit. During an interview on 05/29/2026 at 11:35 a.m., CNA C revealed that she had worked the overnight shift and cared for Resident #4 on 05/14/26. CNA C stated that no staff contacted her about an alleged allegation of abuse. She stated she only found out through word of mouth when her nurse did not show up to work, and she asked why her nurse was not present and RN A informed her that she had been suspended pending investigation of alleged abuse. CNA C stated she received abuse and neglect in-service on 05/15/26 on the overnight shift. She stated that the in-service covered to handle patient carefully, never to be rough and if cause or see any skin concerns to report to the Administrator immediately. During an interview on 05/29/2026 at 12:45 p.m., Resident #4 revealed that she did not remember a staff member pinching her or that she had reported that to anyone. Resident #4 reported that staff had not been rough with her when they provided care. Resident #4 stated that she felt safe in the facility and with the staff that provided her care on all shifts. During an interview on 05/29/2026 at 1:26 p.m., RN B revealed that she was the overnight nurse that worked with Resident #4. She stated she had no knowledge of the allegation of abuse of Resident #4. She stated that the only allegation of abuse that she was suspended for was for a different resident. RN B stated that the DON nor the ADM called to ask her if she was aware of any skin concerns or aware of any bruising on Resident #4. Attempted phone interview with CNA D on 05/29/26 at 2:00 p.m., no answer and no returned call back prior to exit. During an interview on 05/29/26 at 2:15 p.m., the DON stated that a thorough investigation consisted of an interview with the resident, safe surveys, try to identify an alleged perpetrator, if an alleged perpetrator was found, suspend that individual pending investigation, complete in-service, report the allegation to the State, contact the police, notify family and physician, conduct assessments, monitor the resident, pain management if needed, determine outcome of investigation, if unconfirmed allow alleged perpetrator back, provide education to them prior to hitting the floor, and if founded, the alleged perpetrator is terminated. The DON stated she felt this was a thorough investigation. She stated they were unable to determine an alleged perpetrator. The DON stated that she was not aware why staff would state she did not talk to them as she did talk to everyone who she was able to get a hold of that worked on 05/13/26, 05/14/26 and 05/15/26. She stated that she was not sure of the names as she had only been at the facility one week at the time, but had a highlighted list of names of staff she physically talked to and provided those names to the ADM. She stated that she would ask the ADM where the list was because it should have been in the self-report. The DON stated that she was under the impression that the ADM typed up her findings and included them in the self-report. During an interview on 05/29/26 at 2:39 p.m., the ADM stated that as the Abuse Coordinator when there was an allegation he had to speak with the resident, ensure the resident felt safe, see if they were able to identify an alleged perpetrator, and if so contact that person and inform them they were suspended. He stated that if it was reported physical abuse, he'd have a nurse conduct head-to-toe assessment, pain management, contact police department, and notify family. The ADM stated that he would delegate someone to talk to staff and start in-services and safe surveys. He stated if a staff member was identified he would take their statement and report within the allotted time frame the alleged abuse. Then continue the investigation until complete and then decide based off information provided. He stated that dependent on the outcome if unfounded the alleged perpetrator would be able to return with education and if founded would be terminated. The ADM stated that he felt the investigation was thorough and complete. The ADM stated Resident #4 was unable to provide any details or description that would help them determine an alleged perpetrator, Resident #4 felt safe. He stated Resident #4 did not have any pain, in-services and safe surveys were completed. He stated that the DON had called staff who worked days prior to the alleged incident, but no one stated they knew anything. The ADM stated that he did not have any statements provided as they were conducted via phone. The ADM was unable to provide names of who were contacted. The ADM was not aware of who was not contacted. The ADM stated that the DON provided a list of staff she had contacted but was not able to locate the list. He did not believe there was a risk to the residents because he did not find anything concerning that would have led to abuse or neglect and there was no identifiable alleged perpetrator. A record review of safe surveys completed on 05/15/26, no negative findings. Record review of facility policy named Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating from Resident Rights and Abuse Prevention Policy and Procedure Manual 2001, revealedAll reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are retorted to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.10. The investigator consults daily with the administrator concerning the progress/findings of the investigation.11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator.Follow-up2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified.3. The follow-up investigation report will provide as much information as possible at the time of submission of the report.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 6 residents (Residents #23 and #63) reviewed for ADL care.The facility failed to answer Resident #23 and Resident #63 call lights in a timely manner.This failure could place residents at risk for complications associated with delayed care such as skin breakdown and dignity issues.Findings included:Record review of Resident #23's face sheet reflected she was an [AGE] year-old female with an initial admission date to the facility of 02/19/2025. Her diagnosis included Parkinsonism (neurodegenerative disease), Muscle Wasting and Atrophy, and Muscle Weakness.Record review of Resident #23's Quarterly MDS, dated [DATE] reflected that she had a BIMS score of 13 (cognitively intact, normal thinking and memory). The resident required a wheelchair, required substantial/maximal assistance (Helper does more than half the effort) for transfers, showers and could not walk on her own. Resident #23 was always incontinent of bowel and bladder.Record review of Resident #23's Comprehensive Care Plan dated 01/25/2026 revealed that Focus: Resident #23 has an ADL self-Care performance deficit related to impaired balance, limited mobility, Parkinsonism. Goal: Resident #23 will maintain current level of function in ADLs through next review date. Interventions: Transfer: Resident requires Mechanical Lift with 2 staff assistance with transfers. The Resident required total assistance with transfers. The resident requires extensive assistance with, Toilet Use, Bed Mobility, Dressing and Bathing/Showering. Record review of Resident #63's face sheet she was an [AGE] year-old female with an initial admission date to the facility on [DATE]. Her diagnosis included: Fracture of eh Left Femur (Largest bone in the leg) Difficulty in Walking, Unsteadiness on the feet, and Muscle Weakness.Record Review of Resident #63's MDS dated [DATE] reflected that Resident #63's BIMS score was 15 (cognitively intact, normal thinking and memory). Resident #63 was totally dependent (helper does all of the effort) for toileting hygiene, Picking up an Object and Putting on/taking off footwear. She required Substantial/maximal assistance (Helper does more than half) for Lower Body Dressing, Showers/Bathing, Rolling Left to Right, Sit to Lying, Lying to Sitting on Side of Bed. Resident #63 was completely competent of bowel and bladder. Review of Resident #63's Comprehensive Care Plan dated 02/19/2026 reflected that Focus: Resident #23 has an ADL self-care performance deficit related to Impaired Balance, Limited Mobility, Limited ROM, Musculoskeletal impairment. Goal: Resident #63 will Improve current level of function in ADL's through the review date. Interventions: Encourage the resident to use bell to call for assistance. Focus: Resident #63 has an alteration in musculoskeletal status related to fracture of the left femur. Goal: Resident #63's wound will heal and progress without complications through the review date. Interventions: Anticipate and meet needs. Be sure call light is placed within reach and respond promptly to all requests for assistance. In an interview on 03/03/2026 at 1:08 p.m. Resident #63 stated that Call lights could take far too long to be answered. She stated that earlier that morning she had pressed the call light because she had to go to the bathroom, but no one came for over an hour and that she had ended up wetting herself. She stated that it was embarrassing and humiliating to wet herself and that she had never wore adult briefs before but felt she had to wear them now because there had been several times that she had wet herself because call lights were not answered for over an hour. In an interview on 03/03/2026 at 1:33 p.m. Resident #23 had started to cry while stating that the staff often take over an hour to answer her call light. She stated that she didn't want to wait [for help] but that the staff made her wait. An observation on 03/03/2026 at 1:40 p.m. revealed that a call light was observed turning on over resident room [ROOM NUMBER], a CNA was observed entering the room and turning off he call light at 1:52 p.m. and the CNA was observed leaving the room and coming back with a nurse to attend to the resident.In an interview on 03/03/2026 at 4:20 p.m. with the husband of Resident #23 he revealed that he visited his wife everyday after work to care for his wife. He stated that his wife had been at the facility for over a year and that he had witnessed several times himself her call light going unanswered for over and hour. He stated that his wife had told him on several occasions her call light could go unanswered for 1-2 hours. He stated he had spoke to the Administrator a few times about the call lights but that he had seen no improvement in response times.In an interview on 03/05/2026 at 10:03 a.m. CNA K stated that if she is involved in giving showers sometimes it could take her up to 30 minutes to answer a call light. In an interview on 03/05/2026 at 10:24 a.m. CNA L revealed that some residents had complained to her that call lights could take 45 minutes to be answered. She stated that it would be beneficial to possibly have shower aides and then she might be able to attend to call lights more quickly. She stated that residents that have to wait too long to be changed could suffer skin degradation. In an interview on 03/05 at 10:39 a.m. CNA M stated that sometimes during shift changes it could take 45 minutes to answer a call light. She stated that some residents have complained to her that call lights take too long to be answered. She stated that residents might be embarrassed or have skin degradation if they are not helped quickly enough with call lights.In an interview on 03/05/2026 at 12:19 p.m. the ADM stated that he had been working with Resident #65 about their complaints of CNA's being rushed and call light response times by meeting with the resident on a regular basis. He stated that it was important for a residents' psycho-social health and to avoid possible skin degradation for call lights to be answered as quickly as possible and residents to receive help in no more than 15 minutes.A record review of the facility Grievance Files found three Grievances written by Residents #105, #106, and Resident #107, written on 2/19/2026, 2/17/2026, and 02/04/2026 respectively. All three grievances described the wait for call lights to be answered as a very long timeIn an interview on 03/05/2026 at 1:14 p.m. with Resident #105 on the telephone, Resident #105 revealed that she had pressed her call light around 2:00 p.m. and no one had come for over and hour, she stated that she eventually had her son go to the nurses station and ask for someone to come to her room as she needed to have her adult brief changed. She stated that it took nearly 2 hours to get any help from the staff, and it had happened more than once while she had been at the facility.Attempts to reach Residents #106 and #107 via phone on 03/05/2026 at 1:28 p.m. and 03/05/2026 at 1:38 p.m. the surveyor was able to leave messages but the Residents did not call the surveyor back before the end of the survey.In an interview on 03/05/2026 at 3:47 p.m. the DON revealed that her expectation for call lights to be responded too were as quick as possible, CNA's had been instructed to answer call lights in any area of the facility, not just their assigned area. She further revealed that 15 minutes was the upper limit for a call light to be answered, and if call lights were not answered in a timely manner, it could cause incidents/falls or psych-social harm or lead to skin degradation.In an interview on 3/19/26 at 9:22 AM with the ADM and DON the ADM stated that they had assigned some additional duties to the ADON's and that one of those duties were for staffing coordinator. he stated there had not been any more complaints/grievances involving call light response times. The DON remarked that that staff had been instructed to answer call light wherever/whenever they see one, whether it is in their assigned area or someone else's. She stated that all the nurses and staff had been in serviced on Resident Rights, Call Light Response time and Customer Service on 10/1/25, 12/9/25 and on 3/4/26. She stated that the nurses and herself were monitoring call light response time by going into resident rooms on all three shifts and recording the time it takes to be answered, she stated that they would continue to do those exercise for the next 3 months.In an interview on 3/19/26 at 10:30 AM Resident #63 stated that the call light issue was only that one time, but they did improve their response time, and she felt that it was because they were both getting used to each other's schedules. she stated that she had been very satisfied with her stay at the facility and that CNA's and that she had had no other issues at all while she had stayed at the facility. She denied that she had suffered any mental anguish or physical harm as a result of her incident.In an interview on 3/19/26 at 10:48 AM Resident #23 appeared to be in a much better mood. she stated that the call light response times had been much better. [NAME] stated that she was doing fine, and that she had no current complaints.In an interview on 3/20/26 at 10:00 AM CNA K stated that she had received training in answering call lights, resident rights and customer service. She stated that they have had similar training before and she stated that the facility had made one of the ADON's in charge of staffing. She stated that there was also a new rule that if you see a call light go and answer it no matter where you are assigned. She stated that no call light should go unanswered for more than 5 minutes.In an interview on 3/20/26 at 10:09 AM CNA L stated that she had been at this facility for 13 years. She stated that she had received training for call light response time and Resident Rights and customer service recently and remembered having those in-services many times. She stated that staff had been instructed to answer any call light they see no matter where they are assigned to. She stated the ADON was now in charge of staffing, and that no call light should take more than 5 minutes to be answered.In an interview on 3/20/26 at 10:39 AM CNA M stated that the ADON was now in charge of staffing and that she seemed pretty good at it. She stated that all CNA's and Nurses had been instructed to answer a call light, it doesn't matter which hall you are assigned too. She stated that that has helped a lot and she thinks call lights are answered very quickly now. she stated that she received in-services for Res Rights, Call Lights, and Customer serviceReview of a facility Policy titled Answering the Call Light dated September 2022, the policy stated: Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs.1. Answer the resident call system immediately. a. If the resident needs assistance, indicate the approximate time it will take for you to respond.c. If the residents request is something you can fulfill, complete the task within 5 minutes if possible.

Based on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 2 of 6 residents (Residents #25 and Resident #7) completed and accurate records. The facility failed to ensure Resident #7 and Resident # 25 had either a Full Code or a Do Not Resuscitate status listed in the electronic medical record making it unclear as to what the code status was. This failure placed residents at risk of not having their preferences and wishes honored in an emergency.Findings included: Record review of Resident # 25's face sheet, dated [DATE], reflected an [AGE] year-old female admitted [DATE]. Her diagnoses included acute myocardial infarction (heart attack caused by a decreased or complete cessation of blood flow to a portion of the myocardium) bipolar disorder (a chronic mental health condition characterized by extreme and long lasting shifts in mood, energy and activity levels, alternating between high and low states), Parkinson's (a progressive , degenerative neurological disorder that impairs motor function), dementia (a decline in mental ability such as memory loss and reasoning problems), and chronic kidney disease (a long term condition where kidneys cannot filter blood effectively). The face sheet indicated that she was Full Code (a designation indicating that if a patients heart stops, lifesaving interventions will be used) and a DNR (a document directing healthcare providers not to perform cardiopulmonary resuscitation if heart or breathing stops). Record review of current physician orders dated [DATE], reflected an order for Full Code with a start date of [DATE] and a DNR order with a start date of [DATE]. Record review of the OOH-DNR (a document that instructs paramedics or nursing home staff not to perform lifesaving measures. reflected it was executed on [DATE] and was completed with all necessary signatures. Record review of Resident # 25's admission MDS, dated [DATE], revealed a BIMS (Brief Interview of Mental Status) score of 3 which indicated severe cognitive impairment. In an interview on [DATE] at 2:55 p.m. with RN C stated Resident #25 was full code and then stated the EHR indicated Resident # 25 was also a DNR. She checked the actual DNR document and stated that she was a DNR. She was not sure why Resident # 25 had a full code and a DNR status listed on the face sheet. She stated the risk to the residents would be that staff would start CPR and the resident might be a DNR. Record review of Resident #7's face sheet dated [DATE], reflected a [AGE] year-old male admitted [DATE]. His diagnoses included unspecified dementia (a decline in mental ability such as memory loss and reasoning problems), anxiety (a fear of dread, apprehension and tension), depression (a mental illness causing persistent sadness) hypertension (high blood pressure) and Parkinson's (a progressive degenerative neurological disorder that impairs motor function) . The face sheet indicated Resident #7 was Full Code and a DNR. Record review of current physician orders dated [DATE], reflected an order for Full Code with a start date of [DATE] and a DNR order with a start date of [DATE]. Review of the OOH-DNR reflected it was executed on [DATE] and was completed with all necessary signatures. Record review of Resident # 7's Quarterly MDS, dated [DATE], revealed a BIMS score of 9 which indicated moderate impairment.During an interview on [DATE] at 3:09 p.m. with RN D stated that she was not sure what the code status was for Resident #7 because both Full Code and DNR were listed in the EHR. She stated in an actual emergency she needed to know quickly what it was. She stated the risk to the resident was life and death. During an interview on [DATE] at 3: 56 p.m., the social worker stated she spoke with the family and/or resident right after the admission to find out about the code status. She stated she assisted with getting the paperwork completed and scanned into the medical record. She notified the ADON who entered in the order for the code status. She stated the risk to the resident was their wishes might not be followed correctly. During an interview on [DATE] at 4:05 p.m., ADON E stated she had not looked at the code status orders and was not aware until today ([DATE]) that there was an issue. She stated the nurse cannot delay CPR if the nurse cannot find the OOH-DNR. She stated the risk was that staff would not know how to render care. During an interview on [DATE] at 6:12 p.m., Resident #7 stated he did not want CPR and had a document in his records indicating that choice. In an interview on [DATE] at 6:00 p.m., the DON stated when someone was admitted , the nurse and the ADON looked at the orders and the resident ws automatically a full code if there was not an order, if they have a DNR, that order will be added. She stated the company recently changed from EMR system to another and that might have something to do with why someone would have a full code and a DNR order. She stated they were currently doing a full audit to update the system and educate all the nurses. She stated the risk to the residents was that it could go against their rights. Record review of the Advanced Directive policy dated [DATE] reflected in, If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. The residents wishes are communicated to the residents' direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings.

Based on observation, interview, and record review the facility failed to ensure that a resident was offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for one (Resident #65) of three residents reviewed for therapeutic diets. The facility failed to ensure Resident #65 was offered alternative menu items for a therapeutic diet when she did not like the meal and received ordered Boost (supplement shake) instead of Glucerna (supplement shake for diabetes). This failure placed residents at risk of weight loss, receiving the wrong supplement, and not having choices of alternate menu items.Findings included: Review of Resident #65's quarterly MDS Assessment, dated 02/06/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMs score of 8. The resident's cognition was moderately impaired. The resident had diagnoses including cancer, non-Alzheimer's dementia, stroke, malnutrition, and adult failure to thrive. The resident was on a mechanically altered diet. Review of Resident #65's Comprehensive Care Plan reflected:02/01/26 Resident had an unplanned/unexpected weight loss related to failure to thrive.Facility Interventions included: Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss.12/16/25 Resident had a potential nutritional problem related to diet restrictions.Facility interventions included: Provide, serve diet as ordered. Monitor intake and record every meal. Review of Resident #65's Order Summary Report reflected:03/01/26 Pureed diet texture and regular/thin liquids.02/21/26 Boost three times a day for supplement. Review of Resident #65's Weights reflected:12/24/25155.4 pounds01/19/26133.6 pounds02/10/26126.6 pounds03/03/26124.0 pounds Review of Resident #65's Progress Notes reflected:Effective Date: 02/01/26 9:59 PM Nutrition/Dietary Note Weight evaluation: Weight down 19.6% x 30 days and 16.3% x 90 days. Receiving 237 milliliters Glucerna at night, however, weight loss continues. Oral intake appears to have decreased from 50-75% to no 0-25% on puree diet. Receiving health shakes two times a day.Recommend:1. Evaluate for starting appetite stimulant to assist with intake; meeting estimated nutritional needs.2. Continue wound healing supplementation.3. Continue current diet regimen.4. Continue Glucerna and health shakes.Goals: adequate intake, weight stability, intact skin. RD to continue to monitor weight changes, skin breakdown, intake.Author: RD IEffective Date: 02/14/26 4:46 PM Type: Nutrition/Dietary NoteWeight evaluation / skin evaluation. CBW 126.6#, BMI 21.7. Noted significant weight loss of 18.3% x 30 days and 22.7% x 90 days. Weight loss continues. Oral intake poor at 0-50%. Receiving health shakes twice a day for an additional 440 kcal and 14 grams protein. Receiving Glucerna at night to provide an additional 180 kcal and 12 grams protein/day. Medications reviewed; albumin 2.3, glucose 73.Recommend:1. Stop Glucerna.2. Start Boost VHC 120 milliliters three times daily between meals to provide an additional 800 kcal/33 g protein/day.3. 3. Continue health shakes twice a day to provide an additional 400 kcal and 12 grams protein/day.4. Goals: adequate intake, intact skin, weight stability. RD to continue to monitor weight changes, skin breakdown, intake.Author: RD IEffective Date: 02/17/26 8:41 AM Type: Nurses NotesLeft message for son to call back to discuss the med ordered for appetite to get consent, Mirtazapine 7.5 milligrams dailyAuthor: ADON EEffective Date: 03/03/26 at 2:58 PM Type: Nutrition/Dietary NoteNote Text: Physician here and notified of resident weight loss of 7.5% since January. Stat albumin ordered. Resident frequently refusing weekly weights and lab. Will continue to attempt. Dietary Manager spoke with resident today regarding diet alternatives. Resident ate 50% of her meal and was offered fruit and a health shake which she consumed.Author: DONEffective Date: 03/03/26 3:20 PM Type: Nutrition/Dietary NoteNotified resident's son of weight loss and poor appetite. He said he has been aware of her weight loss since she admitted . He said they have discussed a feeding tube and that option is a hard no.Author: DONEffective Date: 03/03/26 3:27 PM Type: Nurses NotesPhysician made rounds and new orders were received. Give Mirtazapine 7.5 milligrams by mouth every night for appetite.Author: ADON E An observation and interview on 03/03/26 at 12:10 PM with Resident #65 revealed she was sitting upright in bed. She said she was waiting on staff to help her sit up and help her eat. CNA F entered the resident's room and said she was going to feed Resident #65. CNA F positioned the resident and removed the lid of the tray. It was a puree diet. The resident ate a few bites of the food. CNA F said if the resident did not like the food on her tray, she could ask if the resident wanted something else to eat. CNA F showed the resident the food ticket and said she could only pick off food from the food ticket. The resident said she liked bread but did not want pureed bread. CNA F said there were no other alternatives for the resident to eat. The resident said she did not want any of the food on the ticket. CNA F said if the resident did not like the food then she could lose weight. An interview on 03/03/36 at 12:39 PM with ADON G revealed the facility did offer an always available menu. ADON G said if the resident did not eat the food, then she could lose weight. ADON G asked Resident #65 what she wanted to eat and she said she wanted chicken salad. ADON G said she would make sure the staff brought chicken salad to the resident. An interview on 03/04/26 at 12:00 PM with Resident #65 revealed she did not like breakfast. She said staff told her they would bring her something different, but they never did. An interview on 03/04/26 at 12:10 PM with CNA F revealed she fed Resident #65 breakfast and she ate 50% of the meal. CNA F said she did not offer her anything else to eat. An interview on 03/04/36 at 12:45 PM with MA H revealed she administered Glucerna on 03/04/26 (supplement shake for diabetic residents) after the lunch meal to Resident #65. MA B said she drank more than half of it. MA B said she gave the resident Glucerna and not Boost as ordered. MA B did not give a reason for giving the resident Glucerna. An interview on 03/04/26 at 1:15 PM with RD I and RD J regarding Resident #65 revealed the facility had been monitoring the resident's weight loss on a monthly basis. They said the resident needed to drink Boost instead of Glucerna because Glucerna was not for limited intake. They said they addressed her weight loss multiple times over months. They said they did not know why staff did not offer her an alternative menu. They said the resident started on mirtazapine (appetite stimulant) on 03/03/26. An interview on 03/04/26 at 1:40 PM with Dietary Manager revealed she spoke to Resident #65 on admission regarding her food preferences. The Dietary Manager said the resident wanted to eat regular food, not puree food. The Dietary Manager said the resident was able to order off the always available menu. An interview on 03/04/36 at 1:55 PM with the DON revealed the resident was not being treated for diabetes. She said she did not know why staff did not offer Resident #65 an alternative meal because she said they usually did. The DON (new to the facility) said she found out about Resident #65's weight loss on 03/03/26 and the Registered Dietician was contacted for review. The DON said she did not know why mirtazapine was not ordered before 03/03/26. The DON said ADON E was in charge of monitoring resident's weight loss. The DON said if a resident was not offered alternative food choices they could become malnourished and dehydrated. The DON said she did not know why MA B gave the resident Glucerna instead of Boost. An interview on 03/04/36 at 2:55 PM with ADON E revealed she was in charge of monitoring weight loss in residents. She said Resident #65 did not have consistent weights and she had to notify the Registered Dietician for a weight loss of more than 3%. ADON E said the resident was offered health shakes and Boost. ADON E said she knew the resident had been refusing meals and did not know how much she ate. ADON E said she did not know why the mirtazapine was not ordered but knew it had been previously discussed An interview on 03/04/26 at 4:00 PM with the DON revealed for weight monitoring, the Registered Dietician would monitor monthly. She said the mirtazapine was not ordered because it was overlooked by ADON E. The DON said Resident #65 was supposed to receive high calorie Boost and not Glucerna. She said that even though the Surveyor intervened and identified the issue with the resident's weight loss; the DON was going through the weights and said she would have found it. The DON said ADON E was responsible for ensuring interventions for weight loss were effective.An interview on 03/04/26 at 5:45 PM with Physician revealed Resident #65's weight loss was identified in December 2025 and January 2026, and interventions were put in place. He said he had discussed getting the resident a feeding tube, but the family said no. He said the mirtazapine was not previously ordered because the resident was very sensitive to medication.A Record Review on 03/19/26 at 11:48 AM of a document titled Order Listing Report Revealed that 23 residents currently had orders for supplements at the facility. Residents #77, #98, #73, #23, #3, and #45 were selected from this list for observations and interviews.A record Review on 03/19/26 at 11:50 AM of Resident #65's Wound Care notes dated 11/4/25 and 03/03/26 respectively, found that the resident had admitted to the facility with several wounds, the wounds had healed slowly over time and had decreased in size, but ultimately the overall prognosis for the resident was poor.In an interview on 3/19/26 at 1:17 PM the DON stated that the facility had a new system for tracking dietary/supplement recommendations/orders. She stated that ADON E was now the nurse in charge of the weight program and a new binder had been developed in which ADON E would sign that recommendations had been communicated to the Physician. She stated that the binder would be in DON's office and that she was monitoring that recommendations/orders were being properly processed by checking the Electronic Health Record System on a daily basis.In an interview on 3/19/26 at 3:43 PM with Resident # 65's son, the son revealed that his mother had had orders from the hospital for a pureed diet because of some swallowing issues and so he insisted she stay on a pureed diet. He stated that he visited his mother twice everyday and that she was always offered alternatives to eat and was offered a variety of liquid supplement shakes but she was very stubborn and she often refused to eat, and she hated Glucerna the most. He stated that he had been made aware of her weight loss by the facility and had many conversations with the nurses and the Physician. He stated that the Physician had recommended a G-Tube but he had flat out refused that option as he knew that was against his mother's wishes. He stated that is mother had decent care at the facility and he had no complaints about her care or treatment.In an interview on 3/19/26 at 4:42 PM the Physician stated that Resident #65 had been very selective about what she would eat and often refused to eat despite being offered alternatives. He stated that receiving Glucerna as opposed to Boost would have made no difference in her weight at all. He stated that she also would refuse to take medications to increase her appetite. He stated that he had had several conversations with Resident #65's son about her weight loss and interventions that they could try including inserting a G-Tube that the son refused to do that. He stated that at that point no interventions would have made a difference as Resident #65 did not want supplements or medications, she had many contributing comorbidities. All of these factors contributed to her wounds healing slowly. Resident #65's attitude and prognosis did not lend to a good outcome.Review of the facility policy, Alternative Foods, not dated, reflected: PolicyAppropriate alternate foods will be prepared and offered at each meal for food preferences.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #104) of five residents, reviewed for infection control. 1. The facility failed to ensure LVN K performed hand hygiene and changed his gloves after treating one wound and moving on to another wound on Resident #104. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Review of Resident #104's Annual MDS Assessment, dated 02/25/26, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were not impaired. His diagnoses included cancer, heart failure, diabetes, cellulitis of the right leg and left leg. The resident had infection of the foot and open lesions other than ulcers. Review of Resident #104's Care Plans, dated 03/03/26, reflected:Actual impairment to skin integrity. Trauma on right lower leg and trauma on right food, 2nd toe. Facility interventions: follow facility protocols for treatment of injury. Review of Resident #104's Order Summary Report, dated 02/24/26, reflected:Cleanse trauma on right lower leg with normal saline, pat dry, apply triple antibiotic ointment, leave open to air, apply every evening shift and as needed.Cleanse trauma on right 2nd toe with normal saline, pat dry, apply triple antibiotic ointment, leave open to air, apply every evening shift as needed. An observation on 03/04/26 at 9:35 AM with WCN revealed he was preparing to provide wound care to Resident #104. Resident #104 was seated in his wheelchair. LVN K cleaned the wound on the right lower leg and applied the treatment. LVN K did not change gloves or perform hand hygiene. LVN K then cleaned the wound on the toe of the right food and applied the treatment. An interview on 03/04/26 at 9:45 AM with the WCN revealed he said it was ok to use the same gloves to treat different wounds. He said he did not know he was supposed to change his gloves and perform hand hygiene between wounds. He said failure to complete hand hygiene and change gloves could lead to infection. An interview on 03/05/26 at 3:47 PM with the DON revealed staff were supposed to change gloves and perform hand hygiene between wounds. She said failure to perform hand hygiene and gloves between wounds could lead to infection. Record review of the facility policy, Handwashing/Hand Hygiene, revised August 2015, reflected: .7. Use an alcohol-based hand rub.or soap.and water for.k. After handling used dressings.

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for three (October 2025, November 2025 and December 2025 of four meetings reviewed for QAPI.1. The facility did not ensure the Infection Preventionist attended the December 2025 meeting.2. The facility did not ensure meeting occurred monthly as per their policy and did not conduct meetings for January 2026 and February 2026.These failures could place residents at risk for quality deficiencies being unidentified, infections, no appropriate plans of action developed and implemented, and no appropriate guidance developed.Findings include:Record Review of the facility's QAPI Committee sign in sheets indicated the Infection Preventionist was absent from the March 2026 meeting. Further review found that the facility was not able to produce Committee sign in sheets for the months of January 2026 and February 2026.In an interview on 03/05/2026 at 12:19 p.m. the ADM stated that the facility's policy is to conduct QAPI meeting on a monthly basis and that the meetings were where they developed new interventions and evaluated the effectiveness of prior interventions. He stated that without the meetings the facility might not be able to effectively keep residents from harm or improve resident lives to a higher standard.In an interview on 03/05/2026 at 3:47 p.m. the DON related that she had recently attended a QAPI meeting on 03/04/2026, she stated that only herself and the Medical Director and the ADM were there. She started that the facility needed all members there to be able to get the information for efficient interventions. Insufficient meetings could impeded the development of setting interventions and reviewing those interventions to see if they are effective.Record review of the facility's policy titled Quality Assurance and Performance Improvement Program, . revised on 02/2020 indicated, Authority (1) The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI Program . 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan .

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 1 of 4 residents reviewed for clinical records (Resident #30). The facility failed to ensure Resident #30's use of bed rails/grab bars was documented in their care plan. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care. Findings included: Record Review of Resident #30's Face Sheet reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #30 had relevant diagnoses of personal history of traumatic brain injury (injury to the brain caused by an outside source), paroxysmal atrial fibrillation (type of irregular heartbeat that occurs in brief episodes of less than 7 days), heart failure, hypertensive heart disease with heart failure (when chronic high blood pressure causes structural and functional changes in the heart), type 2 diabetes mellitus with unspecified complications (chronic condition that occurs when the body does not use insulin properly, causing high blood sugar), cerebral infarction (when blood flow to the brain is blocked causing brain cells to die; ischemic stroke), hemiplegia (complete paralysis of one side of the body) and hemiparesis (partial weakness to one side of the body) following cerebral infarction affecting right dominant side, conversion disorder with seizures or convulsions (psychiatric illness in which psychological conflicts are manifested as physical symptoms), major depressive disorder, difficulty in walking, muscle weakness (generalized), muscle wasting and atrophy multiple sites, other symptoms and signs involving the musculoskeletal system, cognitive communication deficit (communication difficulty caused by cognitive impairment), need for assistance with personal care, pain, primary insomnia, sleep apnea, long term (current) use of anticoagulants, and other lack of coordination. Record Review of Resident #30's Quarterly MDS, dated [DATE], reflected a BIMS score of 6, indicating severe cognitive impairment. Resident #30 was shown to have functional limitations in range of motion of upper and lower extremities. Resident #30 utilized a manual wheelchair for mobility throughout the facility. Record review of Resident #30's Care Plan, last updated on 10/27/2024, reflected that Resident #30 was a fall risk and intervention approaches were to assist with all transfers and mobility, check frequently for safety, encourage activity participation, keep bed in lowest position, keep frequently used items and call light within reach, and observe fall precautions at all times. There was no mention of bed rails/grab bars as a problem or intervention approach in the care plan. Observation of Resident #30's room area and bed on 12/10/2024 at 10:40 AM, and on 12/12/2024 at 11:15 AM revealed bilateral grab bars raised on the bed. Interview on 12/10/2024 at 10:40 AM with Resident #30 revealed the grab bars were used for getting in and out of the bed as well as repositioning. Resident #30 stated he did not remember if there had been an assessment or if he was asked to consent for the grab bars but would if asked. Interview on 12/12/2024 at 10:36 AM with LVN I revealed that residents were to be assessed for safe use of grab bars or bed rails at admission. LVN I stated that each resident was different and some may have needed grab bars or even more such as bed rails but some did not, or would not be safe with the grab bars/bed rails. The nurse conducting the assessment was to obtain a signed consent from the resident or the responsible party, and if they were to refuse to sign the consent, then the resident could not have the grab bars/bed rails on the bed. LVN I stated that the admitting nurse was also responsible to document the results of each assessment so that the IDT was able to make the care plans. LVN I was not sure who was responsible for grab bars/bed rails documentation in the care plans. LVN I stated that it was very important to know why bars were on resident beds and that resident risks could range from causing accidents to residents falling. Interview on 12/12/2024 at 11:22 AM with the ADM revealed that grab bars and bed rails were utilized for repositioning purposes only. The ADM stated that nursing staff were to complete the assessment and obtain consent at admission or when the grab bars/bed rails were requested, and a lot of grab bar requests were family driven. The ADM stated that grab bars/bed rails could be included in a resident's care plan. The ADM stated that the risk of incorrectly placed bed rails/grab bars to the residents could have been detrimental to the resident and the bed rails/grab bars could have been considered a risk. Interview on 12/12/2024 at 11:58 AM with the DON revealed that bed rail/grab bar assessments were conducted by the admitting LVN. The admitting nurse was to conduct the assessment to determine if the resident would be safe and what type and length of grab bars or bed rails would have been most appropriate. Inclusion in the care plan was during the IDT meeting by the MDS nurse or the ADON. The DON stated the care plan should be checked quarterly and if an item was noticed missing before a quarterly review it should be updated at that time or reported to an ADON or the MDS nurse. Record Review of the facility's Bed Safety and Bed Rails policy (C)2001 MED-PASS, Inc. pertinent sections state: Policy Statement: Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Policy Interpretation and Implementation 1. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment . 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision for 1 of 2 residents (Resident #43) reviewed for accidents. The facility failed to safely transfer Resident #43 during a mechanical lift from the bed to the wheelchair. The facility failed to provide safe mechanical transfer by not ultilizing 2 staff members to perform the transfer. This failure could place residents at risk of accidents, injuries, and hospitalization . Findings included: Record review of Resident #43's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included postural kyphosis (this is a bone condition that causes the spine to be rounded), muscle weakness, and long-term use of anticoagulants (blood thinners). Record review of Resident #43's quarterly MDS dated [DATE], section GG Functional Abilities - OBRA /Interim revealed the resident required maximal assistance for chair/bed-to-chair transfer, toilet transfer and tub/shower transfer. Record review of Resident #43's care plan dated 10/4/2023 revealed the resident has declined in ADL function and one of the interventions included Hoyer (mechanical) lift with all transfers. Record review of Resident #43's physician order, dated 10/1/2024, revealed order for Hoyer lift for all transfers with assist of 2 or more. Observation on 12/10/2024 at 10:45am of CNA A during Resident #43's Hoyer lift transfer from bed to wheelchair. CNA A was observed performing the transfer by herself. CNA A was observed providing step-by-step instructions to Resident #43 to follow during the transfer. Resident #43 was transferred from the bed to wheelchair. In an interview on 12/10/2024 at 10:50 CNA A stated that this was a routine that she and Resident #43 had every morning when she used the Hoyer lift to transfer him from the bed to wheelchair. In an interview on 12/10/2024 at 2:49pm Resident #43 stated that his transfer was done 50 percent of the time with one person. He stated there have been no accidents or falls. In an interview on 12/11/2024 at 2:56pm, CNA B stated that he had worked at the facility for 11 months. He stated that Hoyer lift transfer always must be done by 2 people. He stated that's how he was trained to do it, and he had not seen any staff attempting the transfer by themselves at the facility. He stated he would report to the nurse right away if he witnessed it. He had an in-service on using the Hoyer lift back in September 2024 . In an interview on 12/11/2024 at 3:00pm, LVN C stated that all Hoyer lift transfers must be done by 2 people. He had not seen any staff doing the transfer by themselves. He stated if he saw that a staff member was doing it by themselves, he would approach the staff to offer help and then remind the staff that all Hoyer lift transfers must be done by 2 people. In an interview on 12/12/2024 at 10:37am, CNA A stated that when she started in October, she was precepted by a floor CNA and was told to do mechanical lift to Resident #43 for one person. She had an in-service training on 12/10/2024 and stated that the DON trained her to always perform Hoyer lifts with 2 people. In an interview on 12/12/24 at 2:20 PM with the facility's only DON, she stated the facility's mechanical lift policy stated it always must be a 2-person assist. The rationale was because it provided safety for residents, and it prevented resident falls. The DON stated she was the one that trained new staff about transfer safety and mechanical lift techniques when new staff was first hired. The new staff also had a preceptor on the floor. CNA A's preceptor trained her to do it 1-person. When asked what her intervention was for future preceptors to not provide inconsistencies in training, she stated she will provide an in-service training for mechanical (Hoyer) lift once a month instead of every 3 months. She stated that she also assessed new staff's competency by completing a competency checklist including transfer-pivot and she trained new staff on performing Hoyer lift transfer correctly. Record review of the facility's in-service training on 9/13/2024 on the Hoyer lift. CNA B and LVN C attended the training. Record review of Competency Assessment of CNA A on 10/15/2024 with the topic of Transfer-Pivot revealed Satisfactory assessment result. Record review of the facility's Job Specific Orientation Checklist for CNA A revealed she was trained on gait belt/transfer and Hoyer Lift. Record review of facility's Lift and Transfer policy. Policy stated: Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.

Based on observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails and grab bars with the resident or resident representative or obtain informed consent prior to installation for two (Resident #29 and Resident #54) of 4 resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have evidence of informed consent and assessment of the resident for risk of entrapment for bed rails or grab bars for Resident #29 and failed to have evidence of informed consent for bed rails or grab bars for Resident #54. This failure could affect residents who used bed rails/grab bars at risk of the resident not being assessed for bed rails or grab bars, resident/responsible party not being aware of the risks, and informed consent not being obtained from the resident or responsible party. Findings included: 1. Record review of Resident #29's face sheet reflected an [AGE] year-old male who initially admitted to the facility on [DATE] with most recent readmission on 02/09/2022. Resident # 29 had relevant diagnoses of chronic kidney disease stage 3, cellulitis of right lower limb, other symptoms and signs involving the musculoskeletal system, muscle wasting and atrophy, psychotic disorder with delusions due to known physiological condition, unspecified systolic (congestive) heart failure, need for assistance with personal care, cognitive communication deficit, history of falling, pressure ulcer of right buttock stage 2, unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, diabetes mellitus due to underlying condition with ketoacidosis (metabolic complication that happens when the body does not have enough insulin to allow blood sugar into cells to use as energy) without coma, type 2 diabetes mellitus without complications, other specified anxiety disorders, Alzheimer's disease, hypertensive heart disease with heart failure, and atherosclerotic (buildup of fats, cholesterol, and other substances in and on artery walls) heart disease of native coronary artery without angina pectoris. Review of Resident #29's MDS assessment (quarterly), dated 11/16/2024, reflected a BIMS score was not able to be obtained at the time of the assessment. Resident #29's Functional Limitation in Range of Motion was listed as no impairment for upper or lower extremities. Resident #29 was indicated to use a manual wheelchair for mobility. Resident #29 was indicated to need maximal assistance with shower/bathe self and moderate assistance to toileting, upper and lower body dressing, and personal hygiene. Record review of Resident #29's Care Plan, last updated 12/01/2024, revealed the resident was receiving hospice care services. Resident #29 is noted on 11/29/2024 to have declined in ADL functioning with approach (intervention) of 1/2 side rails up X2 to assist self for bed mobility and repositioning initiated on 07/26/2022. Review of Medical Record of Resident #29 revealed no bed rail/grab bar assessment or bed rail/grab bar signed consent form signed by the resident or resident's responsible party or noted to have verbal permission for the enabler bars. Observations on 12/10/2024 at 10:40 AM and on 12/12/2024 at 11:15 AM revealed on both occasions Resident #29's room had the resident's bed with bilateral 1/2 bed rails raised; resident was in bed asleep. Resident was unavailable for interview during attempts made due to being asleep or receiving personal care services by hospice agency. 2. Record review of Resident #54's face sheet revealed an [AGE] year-old male who admitted to the facility on [DATE]. Resident's relevant diagnoses included periprosthetic fracture around internal prosthetic right hip joint, acute kidney failure with tubular necrosis (condition that causes a lack of oxygen and blood flow to the kidneys, damaging them), functional urinary incontinence, periprosthetic fracture around internal prosthetic right knee joint, other symptoms and signs involving the musculoskeletal system, muscle wasting and atrophy, muscle weakness (generalized), neuralgia and neuritis (severe, sharp, or burning pain that follows the path of a damaged nerve), type 2 diabetes mellitus without complications, difficulty in walking not elsewhere classified, and cognitive communication deficit. Review of Resident #54's MDS assessment (admission), dated 11/02/2024, revealed a BIMS score of 12, indicating moderate cognitive impairment. Resident #54's Functional Abilities were documented to be independent with self-care activities and indoor mobility as he utilized a manual wheelchair or walker. Resident #54 was documented to need some help with stairs and functional cognition. Resident #54 was dependent for toileting, lower body dressing, and putting on/talking off footwear. Resident #54 was indicated to have been maximal assistance with shower/bathing. Personal hygiene assistance was indicated to need moderate assistance. Resident #54 was indicated to need moderate assistance with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #54's Care Plan, dated 10/29/2024, revealed the RESIDENT was At Risk For Complications And Worsening Of Existing Wound(S) Surgical Wound To Right Hip R/T Impaired Mobility with approach (intervention) including Turn And Reposition Q 2 Hours And Prn Avoiding Pressure On Any Boney Pressure Areas. Resident #54 was also indicated to have been At Risk For Decline In Adl Function R/T Right Hip Fx with approaches (interventions) including: Observe Hip And Back Precautions At All Times, Provide assistive device for bed mobility, e.g., side rails and Turn With Assist Of Two People Every 2 Hours When In Bed. Never Bend Of Twist Torso Or Make Sudden Movements During Adl Care. Resident #54's care plan also included Resident Has Declined In Adl Function with approach (intervention) of 1/2 Side Rails Up X 2 To Assist Self For Bed Mobility And Repositioning. Review of Medical Record of Resident #54 revealed no signed bed rail/grab bar consent form signed by the resident or resident's responsible party or noted to have verbal permission for the enabler bars. Observations on 12/10/2024 at 1:35 PM and 12/12/2024 at 10:25 AM revealed Resident #54's room had the resident's bed with 1/2 bed rails raised on both sides. The resident was not in room at the time of observation on 12/12/2024. Interview with Resident #54 on 12/12/2024 at 10:25 AM occurred in the hallway. Resident #54 stated he did not remember if he or his son had signed any consents when he admitted to the facility from the hospital. Interview on 12/12/2024 at 11:22 AM with ADM revealed that grab bars and bed rails were utilized for repositioning purposes only. The ADM stated that nursing staff were to complete the assessment and obtain consent at admission or when the grab bars/bed rails were requested, and a lot of grab bar requests were family driven. If the resident was assessed as not able to be safe with the grab bars/bed rails, then the reason would be discussed with the resident and responsible party why the grab bars/bed rails would not be placed on the bed. The ADM stated that grab bars/bed rails could be included in a resident's care plan. The ADM stated that the risk of incorrectly placed bed rails/grab bars to residents could have been detrimental to the resident and the bed rails/grab bars could have been considered a risk. The ADM stated it was pointed out by a nursing staff member that the consent form for grab bars/bed rails was no longer showing at the end of the assessment in the EHR, but he had not had time to further investigate what had changed or happened. Interview on 12/12/2024 at 10:36 AM with LVN I revealed that residents were to be assessed for safe use of grab bars or bed rails at admission. LVN I stated that each resident was different and some may have needed grab bars or even more such as bed rails but some did not, or would not be safe with the grab bars/bed rails. The nurse conducting the assessment was to obtain signed consent from the resident or the responsible party and if they were to refuse to sign the consent then the resident could not have the grab bars/bed rails on the bed. LVN I stated that the admitting nurse was also responsible to document the results of each assessment so that the IDT was able to make the care plans. LVN I was not sure who was responsible for grab bars/bed rails documentation in the care plans beyond the IDT. LVN I stated that it was very important to know why bars were on resident beds, that the resident and responsible party should know the risks and benefits, and that resident risks could range from causing accidents to residents falling. Interview on 12/12/2024 at 11:58 AM with the DON revealed that bed rail/grab bar assessments were conducted by the admitting LVN. The admitting nurse was to conduct the assessment to determine if the resident would be safe and what type and length of grab bars or bed rails would have been most appropriate and obtain signed consent. Inclusion in the care plan was during the IDT meeting by a MDS nurse or the ADON. The DON stated the care plan should be checked quarterly and if an item was noticed missing before a quarterly review it should be updated at that time or reported to an ADON or the MDS nurse. The DON stated she did not know why there was no assessment for Resident #29 and no signed consent forms for Resident # 29 and Resident #54. Record review of the facility's provided Bed Safety and Bed Rails, (C)2001 revealed the policy statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bedrails is prohibited unless the criteria for use of bed rails have been met. Policy Interpretation and Implementation item #1 states The resident's sleeping environment is evaluated by the interdisciplinary team. Policy Interpretation and Implementation item #2 states Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. Policy Interpretation and Implementation item #10 states additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment (e.g., altered mental status, restlessness, etc.). Under the Use of Bed Rails section item #1 states . For the purpose of this policy bed rails include: a. Side rails; b. Safety rails; and c. Grab/assist bars Use of Bed Rails section item #3 stated The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Use of Bed Rails section item #5 states If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; b. the resident's risk associated with the use of bed rails; c. input from the resident and/or representative; and d. consultation with the attending physician. Use of Bed Rails section item #8 states Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication rooms (Med Room A) reviewed for pharmacy services. The facility failed to ensure Med Room A did not have expired insulin. This failure could place residents at risk of receiving expired medication and not having appropriate therapeutic effects. Findings included: Observation and interview of Med Room A with the DON on 12/11/24 at 07:30 AM, revealed in the fridge was an insulin pen Insulin Lispro Injection 100 units per ml. Dispensed 04/28/23. The insulin pen was dated as opened on 7/25/24 and labelled to discard 28 days after opening. Insulin pen did not reflect residents name on it. The DON stated that the insulin pen should have been discarded 28 days after opening. The DON did not state the risk to residents for having expired insulin. She stated, You are going to cite me for only one insulin that is expired? In an interview with the DON on 12/12/24 at 2:00 PM she stated the expectations were that expired or undated medications were discarded according to guidelines. She stated the risk for expired medication and undated medication was inactive medications. The DON stated all nursing staff were responsible for the medication rooms and moving forward, herself, and the ADONS will round to make sure that carts were locked, and no undated or expired medications were in the fridge. In an interview with the Administrator on 12/12/24 at 2:24 PM, he stated the expired insulin was discarded immediately. He stated the risk of expired medication was that it can be ineffective. Review of facility policy tilted Medication Labeling and Storage revised February 23, read in part reflected The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .

Based on observations, interviews, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the medication cart for 1 of 7 medication carts (Med Cart C) and 2 of 2 medication rooms (Med Room A and Med Room B) reviewed for storage of medication. 1.The facility failed to ensure drugs and biologicals were labeled. Med Room B had unlabeled and undated TB vaccine and food was stored next to medications in the fridge. 2.The facility failed to ensure Med Cart C was kept locked or under direct observation of authorized staff in an area where residents and family could access it outside Resident #209's room. These failures of the facility to accurately label and safely secure storage of all medications places residents at risk for more than minimal harm. Findings included: 1. Observation and interview of Med Room B with LVN D on 12/11/24 at 07:39 AM, revealed House stock multiple dose TB skin vaccine with a dispensed date of 03/22/24 named Tuberculin Purified Protein Derivative, diluted Aplisol 5 TU /0.1 mL solution. The vaccine was open with cap removed, box was open, and the vaccine was undated with an open date. A yogurt was observed on the shelf nested between the insulins in the back. LVN D stated the vaccine should have had a date on it to indicate when it was opened so that they can knew when to discard it. LVN D stated she was not aware of whom did not date the vaccine. LVN D stated the vaccine was good to be used within 30 days of opening it. She stated that she would discard the vaccine right away. She stated the risk was not knowing if the vaccine would be effective to administrator causing potency ineffectiveness. LVN D stated the yogurt belonged to one of the residents. She stated she was confused about the storage of food in the same fridge as medication. She stated all nurses were responsible for dating medication when opened and all nurses were responsible for discarding expired medication accordingly. 2. Review of Resident #209's face sheet dated 12/11/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were stroke due to embolism (blockage) of the left brain, problems communicating, muscle weakness, high blood pressure, and reflux diseases. The family was the RP. Review of Resident #209's care plan dated 12/02/24 revealed Resident #209 had a memory/recall problem related to stroke. The goal was the resident would improve memory/recall ability as evidenced by recalling staff names, stating he/she was in a nursing home, recognizing staff faces, etc., The interventions were providing verbal and visual reminders, to tell resident who you were, to remind resident of where she was. The care plan also reflected Resident #209 had moderate impaired vision. The goal was that the resident would not experience negative consequences of vision loss as evidenced by remaining physically safe and participating in social and selfcare activities. The interventions were to assess effects of vision loss on resident functional status, to ensure that the lenses of the glasses were clean and in good repair, and to provide adaptive equipment/materials such as large print. Observation on 12/11/24 at 07:50 AM to 08:05 AM, revealed a medication cart unlocked with the lock mechanism released to indicate it was unlocked. The medication cart was unattended. The door to Resident #209's room was almost closed, and the privacy curtain was drawn. There was a sink near the door entrance and a family member was observed washing his hands and he looked at the state surveyor and said there was someone here. RN E then came to the medication cart. In an interview with RN E on 12/11/24 at 08:05 AM, she stated she should have locked the medication cart while she was inside the room. She stated anyone could open the cart and have access to what was inside like medications and needles. She stated she left the cart open because she was only going inside the room for a short while. In an interview with the DON on 12/12/24 at 2:00 PM she stated the expectations were that expired or undated medications were discarded according to guidelines and that the medication cart was locked when not in direct eye view and when it was unattended. She stated the risk to residents was safety for unlocked medication cart and the risk for expired medication and undated medication was inactive medications. The DON stated storing food items next to medication can cause cross contamination. She stated all nursing staff were responsible for the medication rooms and moving forward, herself, and the ADONS will round to make sure that carts were locked, and no undated or expired medications were in the fridge. In an interview with the Administrator on 12/12/24 at 2:24 PM, he stated RN E told him she had just turned her back from the medication cart to say hi to the resident. He did not state the risk of leaving the cart unlocked and unattended. The Administrator stated as for the undated vaccine there was another one in the fridge that was dated and active. He stated, there was only one yogurt. Review of facility policy tilted Medication Labeling and Storage revised February 23, read in part reflected The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly .

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program, designed to provide a safe, sanitary, and comfortable environment, and help prevent the development and transmission of communicable disease and infection, for two residents (Resident #2 and Resident #7) of eight residents reviewed for infection control practices. CMA F failed to perform hand hygiene between residents while alternately feeding Resident #2 and Resident #7. This failure had the potential to result in the spread of infection. Findings included: Review of Resident #2's face sheet, dated 12/12/24, reflected Resident #2 was an [AGE] year-old female, admitted on [DATE], with diagnoses of unspecified dementia, schizoaffective disorder, pain, and fall history. Review of Resident #2's Significant Change MDS assessment, dated 09/29/24, reflected she had impaired vision, and was rarely or never understood or able to understand others. The staff assessment of her cognitive skills reflected severely impaired cognition (rarely or never made decisions), and an acute change in mental status from her baseline. Resident #2 exhibited continuous inattention. The staff assessment of her mood scored 9, indicating possible mild depression. She exhibited no behavioral problems. Resident #2 used a wheelchair and required staff to meet all of her ADL needs. Review of Resident #2's care plan, dated 05/08/15 and edited 12/01/24, reflected (Resident #2) requires assist from staff with all of her meals. Review of Resident #7's face sheet, dated 12/12/24, reflected Resident #7 was a [AGE] year-old female, admitted on [DATE], with diagnoses of dementia, history of repeated falls, fractured leg and fractured hip, and need for assistance with personal care. Review of Resident #7's Quarterly MDS assessment, dated 09/13/24, reflected she was able to understand others, and be understood by others. She had highly impaired vision, and adequate hearing. Resident #7 had a BIMS score of 3, indicating severe cognitive impairment, and had an acute change in mental status from her baseline. She exhibited continuous inattention and fluctuating disorganized thinking. Resident #7 showed no indicators of depression and no behavioral problems. The document reflected Resident #7 used a wheelchair, and required supervision or touching assistance for eating, and for her helper(s) to perform more than half the effort (substantial/maximal assistance) for most other ADLs. Review of Resident #7's care plan, dated 08/14/18 and revised 09/13/24, reflected (Resident #7) is at risk for impaired nutrition related to disease process. Review of Resident #7's care plan, dated 07/13/20 and revised 09/13/24, reflected (Resident #7) HAS POTENTIAL FOR WEIGHT LOSS RELATED TO POOR APPETITE. Observation on 12/11/24 at 11:49 AM revealed CMA F sitting down between Resident #2 and Resident #7. She prepared Resident #2's tray, and handed Resident #7 her drink, which the resident was able to drink some of by herself. She began to feed Resident #2, then took Resident #7's drink from her, and began to feed Resident #7. She alternated feeding each resident bites of their food. Resident #7 roughly grabbed the dessert dish off her tray and appeared about to do something with it, and CMA F removed it from the resident's hand and replaced it on the tray. After the replaced the dessert dish was on the tray, she rubbed her finger across the corner of the tray, as if to wipe something off her finger, onto the tray. She continued to alternately feed the two residents, turning to face the resident she was feeding each time, until 12:00 PM when CNA G approached the table, sat next to Resident #7 and began to feed her while CMA F continued to feed Resident #2. CMA F did not perform any hand sanitation during the entire observation. An interview on 12/11/24 at 12:22 PM with CMA F revealed she was the medication aide, but she could not administer medication during meals, so she was helping out. She said she did not normally feed two people at once, but the other aide was still passing trays, so she was helping. She said it would not be good to feed one resident in front of the other, so she was doing both until CNA G came to feed one of the residents. When asked about feeding two people at once while not doing hand sanitation in between residents being an infection control issue, she said she washed her hands thoroughly before starting to feed them, and she was fully turning her body to face each resident when feeding them. She asked the state surveyor what she should do to correct the problem, because she could not just leave one resident sitting without food, while she fed another resident right in front of them. An interview on 12/11/24 at 12:30 PM with LVN H revealed she did not know if the aides had specifically been trained on how to feed two residents at the same time, but they had been trained to always use hand hygiene between feeding residents for infection control. She said it was not their normal practice to feed two residents at once. An interview on 12/12/24 at 1:59 PM with the DON revealed they avoided feeding two residents at once, as much as possible, but if they had to, they would be expected to sanitize their hands between each resident. She said they would do that in order to avoid cross contamination. An interview on 12/12/24 at 2:24 PM with the Administrator revealed if the staff had to feed two residents at once, they should sanitize their hands between residents. Review of the Assistance with Meals policy, revised 05/22, did not address hand hygiene during feeding residents. Review of the Handwashing/ Hand Hygiene policy, revised 10/23, reflected Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene: 1. Personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. ( .) Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. immediately before touching a resident; ( .) c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; ( .) 2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for 2 of 4 (Medication Cart #1 and Medication Cart #2) medication carts reviewed for pharmacy services. Medication cart #1 was observed unlocked and unattended with 6 blister packs medication cards left on top unsupervised by MA P for 4 minutes. Medication cart #2 was observed outside resident room facing hallway where individuals passed, unlocked and unattended for 2 minutes by RN N. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: In an observation on 02/23/24 at 8:15 AM, Medication cart #1 was observed unlocked and unattended with 6 blister medication filled packs placed on top, in the small resident dining areas on the north side of nursing station. There were 2 residents observed sitting behind the near the medication cart at the tables appropriately 2.5 feet away. MA P returned to her medication cart 4 minutes later, and she immediately removed the blister medication cards and locked inside of the cart. In an interview with MA P on 02/23/24 at 8:20 AM, revealed she forget to lock the medication cart. She stated it was the overnight nurse who left the medication packs on top of the cart. She said overnight nurse was at the facility upon her arrival to work on 02/23/24 at 6:00 AM. She said it was the assigned medication person's responsibility to keep medications locked and inaccessible during her assignment. MA P said all medications should be inside the locked medication cart to prevent medication from being stolen, or residents accessing the medication. An observation on 02/23/24 at 8:25 AM, revealed medication cart #2 positioned in front of a resident room with drawers facing the hallway unlocked. In an interview on 02/23/24 at 8;30 AM with RN N, she stated that she forgot to lock the medication cart. She stated she did not know State was in the building. She said medication carts should be locked regardless to prevent resident access to medications. In an interview with the ADON on 02/23/24 at 1:30 PM, revealed all medication carts should be locked when unattended to maintain safety and prevent others from taking medication. The ADON said medications should never be left on top of a medication cart. The ADON said failing to lock medication carts and secure medications properly could lead to residents having access and other dangerous health response. In an interview on 02/23/24 at 1:40 PM, the DON revealed medication carts must remain locked when unattended to prevent residents, staff, and visitors from accessing. This could lead to missing medication, resident having a bad reaction causing a dangerous medical event. An interview with the administrator was not conducted, due to being absent from the facility on the day of exit. Record review of facility policy titled Administering Medications version 1.2 (H5MAPL0630) undated reflected The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist.9. The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to): a. acquisition and availability of medications: (1) receipt, labeling and storage of medications. (2) reconciliation of medications from the pharmacy. (3) control of medications from point of receipt to secured storage areas; and (4) facility staff roles and responsibilities during the receipt and storage of medication. b. medication packaging and dispensing systems. c. administration of medications. d. disposition of medications. e. authorization, training, and competency of personnel; and f. documentation of processes, as applicable.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 2 (Resident # 82 and Resident #83) of 3 residents reviewed for respiratory care, in that: The facility failed to ensure Resident #82 oxygen tubing and nasal cannula were kept off the floor and bagged when not in use. The facility failed to ensure Resident #83's oxygen tubing was being changed weekly as ordered based on the EMAR and interview with the resident. These failures could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings include: Record review of Resident #82's face sheet dated 02/23/24 reflected a [AGE] year old female admitted on [DATE] with diagnoses of: Alzheimer's disease (memory loss) Congestive Heart Failure (impaired blood pumping function in the heart) 9 Generalized anxiety disorder (fear and worry of unknown), Need for assistance with personal care, Other abnormalities of gait and mobility, Other lack of coordination Cognitive communication deficit, Hypoxemia (Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the body.) Record review of Resident #82s quarterly MDS dated [DATE] reflected resident needed setup for meals, substantial assistance for toileting, hygiene, and showers, moderate assistance for dress, partial moderate assistance for sit to stand. Resident #28's use of oxygen was addressed. BIMS score of 11 indicated he was moderately cognitive impairment. Record review of Resident #82's care plan dated 01/27/24 reflected monitor for s/s of COVID-19 Q shift. Notify MD of any fever or temp greater than 99.0; new onset of cough, sore throat, shortness of breath; vomiting/diarrhea; new loss of smell/taste; fatigue, headache and body-aches Every Shift Day 06:00 - 2:00 PM, Evening 14:00 - 8:00 PM resident will have no complications from cardiac disease over next review date section respiratory system (airway, respirations, and O2 Care plan did not address oxygen use. Record review of Resident #82's EMAR on 02/23/24, reflected there weren't any MD orders for oxygen. In an observation and interview on 02/23/24 at 8:19 AM with Resident #82 revealed resident sitting in her recliner partially leaned back, eating fruit. Resident #82's oxygen tubing was touching the floor and the nasal cannula was positioned on top of concentrator undated, labeled, or bagged. Resident said she did not know if the facility changed her oxygen tubing. She does not know if she uses oxygen. Resident #83 Record review of Resident #83's face sheet dated 02/23/24 reflected an [AGE] year-old female admitted on [DATE]. Resident #83's diagnoses include: Acute respiratory failure (difficulty with lungs loading blood with oxygen) with hypoxia (Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood), Pneumonia, (inflammatory disease affecting the lungs) unspecified organism, Cognitive communication deficit (difficulty expressing thoughts). Record review of Resident #83's MDS dated [DATE] reflected BIMS of 10 - indicating she was moderately impaired cognitively, depression and mood .required Setup or clean-up assistance - ADL partial/moderate assistance self-care- Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort hygiene and mobility, sit to stand Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Record review of Resident #83's admission care plan dated 02/06/24 impaired mobility, impaired strength, and poor safety awareness. observe fall precautions at all times .medication administration: resident at risk for adverse reactions to medications r/t side effects assess for s/s of respiratory failure such as SOB, confusion, restlessness, irritability, inability to move secretions .infection: admitted to community with an active infection. -monitor vital signs every shift. document and report any presence of fever or s/s of atypical manifestations oxygen: administer oxygen as ordered to maintain oxygen saturation >92%, observe oxygen precautions. monitor oxygen saturation via pulse oximetry q shift and PRN. Record review of Resident #83's care plan dated 2/14/24 did not address the use of oxygen or treatment related to respiratory follow all MD orders, assess, and report changes Record review of Resident #83's MD orders dated 02/06/24 reflected respiratory: O2 at 2L/MIN AT start - per NC - titrate (measure) up 1l/min to maintain 02 sats >92% special instructions: continuous o2 at 2l/min to maintain o2 sats >92% - titrate 1l/min progressively and check o2 sats until maintained at > 92% - contact physician if unable to maintain o2 sats >92% every shift - prn 1, prn 2 .respiratory: change tubing on oxygen special instructions: change tubing Q Wk. and note in nursing notes once a day on Fri 07:00 - 21:00 (respiratory nursing) respiratory: Clean Air Filters on Oxygen Concentrators Special Instructions: Change Air Filters Q WK and note in nursing notes Once A Day on Wed 07:00 - 21:00. Record review of Resident #83's e-MAR reflected that on 02/10/24 through 02/23/24 administration record was blank for tubing change. In an observation and interview with Resident #83 on 02/23/24 at 8:20 AM, revealed her nasal cannula tubing and water bottle was undated. She was wearing her nasal cannula and oxygen concentrator was working. She said staff had not changed her tubing since she admitted from the hospital. In an interview with RN-R on 02/23/23 at 12:50 PM, revealed nurses wase expected to change oxygen tubing and date every Sunday during the overnight shift. All nurses should conduct rounds and assess oxygen and look for dates. If not dated check TAR, changing tubing, date tubing, and document changes. Failure to change oxygen tubing routinely could result in respiratory infections. He stated that he had conducted rounds and prior to DON notifying him of resident tubing and water bottle being undated, he had not observed. He said he had changed the tubing and water and dated them. He said water bottles for oxygen concentrators should be dated and changed when empty. In an interview with the ADON on 02/23/23 at 1:30 PM, revealed water bottles should be changed when empty and as needed, then dated to confirm change. The ADON said nursing should be conducting rounds every 2 hours, assuring tubing that was not being used was bagged and dated. The ADON said nurses should change and date tubing and water bottles as soon as possible if found undated, then date and document. The ADON said the negative outcome of failing to date and bag tubing, can lead to the resident receiving respiratory infections. It is the responsibility of the nursing managers (ADON, DON) to monitor. In an interview on 02/23/24 at 1:40 PM, the DON revealed all documentation of tubing changes should be listed in the MAR. She said Resident #82 does not receive oxygen and will remove the concentrator. She expects nursing staff to change oxygen tubing and dating change weekly, document in EMAR. She initially said the tubing and water bottle does not need to be dated. She then stated the importance of dating tubing and water bottle allows nursing to see the tubing was changed immediately upon observation, however she expects review of e-MAR to confirm. The DON said not dating and labeling tubing could lead to infections. The DON said she expects the ADON to audit and monitor nursing task for compliance. An interview with the administrator was not conducted, due to being absent from the facility on the day of exit. Policy for oxygen was requested from ADM on 02/21/24 and DON on 02/22/24 and was not provided to surveyor at the time of exit on 02/22/24.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #82) of 3 residents reviewed for safe , clean, sanitary, and comfortable environment. The facility failed to ensure Resident #82's rooms were free of smeared oatmeal, hard colorful candies, blanket on the floor obstructing walk path for resident #83 with a history of falls. This failure could place residents at risk falls, injuries, and unsanitary care. Findings included: Record review of Resident 82's dated 02/23/24 face sheet reflected a [AGE] year old female admitted on [DATE] with diagnoses of: Alzheimer's disease (memory loss) Congestive Heart Failure (impaired blood pumping function in the heart) 9 Generalized anxiety disorder (fear and worry of unknown), Need for assistance with personal care, Other abnormalities of gait and mobility, Other lack of coordination Cognitive communication deficit, Hypoxemia (Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the body.) Record review of Resident #82s quarterly MDS dated [DATE] reflected resident needed setup for meals, substantial assistance for toileting, hygiene, and showers, moderate assistance for dress, partial moderate assistance for sit to stand. BIMS score of 11 indicating moderate cognitive impairment. Record review of Resident #82's care plan dated 01/27/24 reflected monitor for s/s of COVID-19 Q shift. Notify MD of any fever or temp greater than 99.0; new onset of cough, sore throat, shortness of breath; vomiting/diarrhea; new loss of smell/taste; fatigue, headache and body-aches Every Shift Day 06:00 - 2:00 PM, Evening 14:00 - 8:00 PM resident will have no complications from cardiac disease over next review date. In an observation and interview on 02/23/24 at 8:19 AM, with Resident #82 revealed resident sitting in recliner with smeared oatmeal on the floor, hard chocolate candies red, yellow, blue, and brown on the floor, and a red blanket laying in the walkway to the left of the resident. Resident #82 said she spilled her breakfast plate on the floor, and staff were returning to clean. She did not know how long it had been since the staff left the room. Interview with agency CNA S on 02/23/24 at 8:14 AM, revealed when called to room by Resident #82, she picked up the dishes of the floor and used a napkin to clean the oatmeal. She did not observe the hard candy and blanket on the floor. She said resident floors should be free of objects, food, water, and blankest to prevent trips, falls, and injuries. CNA S said she was not familiar with this resident's ability to self-ambulate. In an interview with RN R on 02/24/23 at 12:50 PM, revealed the expectation for all resident rooms to be free of clutter and objects to prevent accidents and injuries from occurring. He stated all staff were responsible for removing hazards of the floor then contact housekeeping immediately to prevent injuries. In an interview with the ADON on 02/23/24 at 1:30 PM, revealed she expected the nursing staff to keep all residents' floors and rooms free of clutter, food, obstacles to prevent accidents and injuries from occurring. In an interview on 02/23/24 at 1:40 PM, with the DON revealed staff are responsible for maintaining a safe clean environment free of objects, food, and obstacles to prevent falls and injuries for all. She expects staff to remove immediately and notify nurse and housekeeping to address spills. Record review of Facility policy titled Homelike Environment undated version 1.3 (H5MAPL1202) reflected Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary, and orderly environment.

Based on record reviews and interviews, the facility failed to transmit MDS data for 3(Resident #64, 41, 26) of 5 residents reviewed for MDS transmission. The facility failed to transmit a Discharge MDS for Residents # 64, 41, and 26. This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes. Findings included: Record review of Resident #64's Face sheet dated 11/08/23 revealed an admitted [DATE] and a discharge date of [DATE]. Record review of Resident #64's MDS list dated 11/08/23 revealed a Discharge with Return Anticipated MDS completed on 06/02/23 that had not been transmitted. Record review of Resident #41's Face sheet dated 11/08/23 revealed an admitted [DATE] and a discharge date of [DATE]. Record review of Resident #41's MDS list dated 11/08/23 revealed a Discharge with no Return Anticipated finalized on 07/11/23 that had not been transmitted. Record review of Resident #26's Face sheet dated 11/08/23 revealed an admitted [DATE] with a discharge date of [DATE]. Record review of Resident #26's MDS list dated 11/08/23 did not reveal a Discharge MDS finalized, completed, and/or transmitted. During an interview on 11/08/23 at 11:31 with CRN, DON, and ADM, CRN said she usually signed the MDS that it had been completed. She said she did not check that they were submitted. DON said that she did not handle or work with the MDS's for the facility. ADM and CRN both said no person oversaw that MDS's were submitted other than the MDS coordinator. CRN said the MDS coordinator went on vacation last Thursday (11/02/23) so they should have already been submitted. ADM said they did a triple check every month so the MDS's would have been flagged and they would not have been able to complete the triple check without those being transmitted. CRN said she would attempt to get on the MDS submission website and see if she could find out although she did not have access to this facility's submissions. During an interview and record review on 11/08/23 at 01:14 PM with ADM, he provided a review on his computer of their Triple Check for the 3 named residents. He showed that even though there was an area to put information about the resident's MDS status, all 3 residents were blank in that area. He said it would be the triple check they did each month as a monitoring, otherwise they did not oversee and monitor the progress of the MDS coordinator. Record review of CMS RAI Version 3.0 Manual last revised October 2023 revealed: For a Quarterly, Significant Correction to Prior Quarterly, Discharge or PPS assessment, encoding must occur within 7 days after the MDS completion Date . Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 +14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . Discharge Assessment Submit By Z0500B + 14.

Based on observation, interview, and record review the facility failed to maintain infection control procedures designated to provide a safe environment to help prevent the development and transmission of COVID-19 for 17 of 18 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18) residents reviewed for infection control. 1. The facility failed to screen staff and visitors for temperature, signs and symptoms of Covid 19, and close contact with someone known to have Covid 19. 2. The facility failed to quarantine residents with known close exposure. 3. The facility failed to provide policies and procedures for surveillance documentation involving identifying, tracking, monitoring, and/or reporting infections. 4. The facility failed to ensure employees use appropriate hand hygiene and correctly wear a N95 mask. An Immediate Jeopardy (IJ) was identified on 10/4/21 at 1:30 pm. While the IJ was removed on 10/6/21 at 5:36 pm, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The IJ Template was provided to the Administrator on 10/4/21 at 2:38 pm. These failures placed residents at risk of exposure of Covid 19 virus which could result in serious illness, hospitalization , and/or death. Findings included: 1. An observation on 10/1/21 at 5:07 pm revealed 2 emergency medical technicians entered the facility for a non-emergency transport of resident, without being screened. Record review of staff screening logs for August and September 2021, provided on 10/1/21, revealed the facility failed to screen any staff for signs and symptoms of Covid 19 or known close contact with a Covid 19 positive person from 8/8/21 - 9/30/21. The screening log indicated temperature and the following questions: domestic travel, international travel, and worked at another facility. Record review of visitor Covid-19 screening log for August, September, and October 2021, revealed the facility failed to do the following: - obtain visitor name on 21 screenings - obtain visitor temperature on 33 screenings - obtain if the visitor had signs or symptoms of Covid 19 on 20 screenings - obtain if the visitor had close contact with a Covid 19 positive individual on 29 screenings. - 7 instances of visitors reporting signs and symptoms of Covid 19 - 8 instances of visitors reporting close contact with a Covid 19 positive individual; the screening log did not indicate if the visitor was allowed entrance into the facility. Record review of staff screening logs for September and October 2021, provided on 10/4/21, revealed the facility failed to screen any staff for known close contact with a Covid 19 positive person from 9/6/21 - 10/4/21. The screening log indicated date and time, employee name, temperature, signs and symptoms of Covid 19, and if the individual was allowed entry into the facility. Record review of LTC (long term care) Respiratory Surveillance Line List revealed, between 8/8/21 and 10/4/21, 18 residents and 15 staff tested positive for Covid 19. In an interview on 9/30/21 at 12:50 pm with DON revealed the facility does not have an infection prevention control policy, including a surveillance plan or Covid policies; the facility follows the Health and Human Services nursing facilities Covid response plan . In an interview on 10/1/21 at 5:09 pm with Receptionist M revealed she was responsible to complete screenings of visitors, during her work hours. Receptionist M reported she takes temperatures on all visitors who enter the building but does not always complete the entire screening . Receptionist M reported anyone coming into the building should not have to be asked about signs and symptoms of Covid 19 or if the visitor has had close contact with a person who was positive for Covid 19; because people should be honest when answering questions on the screening log. Receptionist M also reported there was not a negative outcome, for residents, if visitors are not screened every time, they enter the building . In an interview on 10/2/21 at 7:46 am with the Administrator revealed the facility does not have a policy regarding screening of staff and visitors; the facility follows the Health and Human Services nursing facilities Covid response plan . In an interview on 10/2/21 at 10:50 am with the Administrator revealed the facility does not have a policy regarding which entrances should be used , screening of visitors or employees, or monitoring of visitation ; the facility follows the Health and Human Services nursing facilities Covid response plan. Record review of the COVID-19 Response Plan for nursing facilities, dated 7/20/21, revealed - To Do's for Nursing Facilities: . actively screen, monitor, and surveil everyone who comes into the NF (nursing facility). - Interim Guidance for Prevention, Management and Reporting of Covid 19 Outbreaks in LTC Facilities .active screening . The CDC and CMS recommend, and the NF Covid 19 Response rules require, NFs screen all staff prior to entering the NF at the beginning of their shift for fever and symptoms consistent with Covid 19. 2. Record review of the facility's resident positive timeline from 08/08/21 until 09/28/21, indicated 18 positive residents with 6 currently in-house. a. Resident #1 tested positive on 8/8/21 b. Resident #2 tested positive on 8/13/21 c. Resident #3 tested positive on 8/13/21 d. Resident #4 tested positive on 8/16/21 e. Resident #5 tested positive on 8/18/21 f. Resident #6 tested positive on 8/20/21 g. Resident #7 tested positive on 9/20/21 h. Resident #8 tested positive on 9/20/21 i. Resident #9 tested positive on 9/24/21 j. Resident #10 tested positive on 9/24/21 k. Resident #11 tested positive on 9/24/21 l. Resident #12 tested positive on 9/24/21 m. Resident #13 tested positive on 9/26/21 n. Resident #14 tested positive on 9/26/21 o. Resident #15 tested positive on 9/26/21 p. Resident #16 tested positive on 9/26/21 q. Resident #17 tested positive on 9/28/21 r. Resident #18 tested positive on 9/28/21. In an interview on 10/1/21 at 9:39 am with the Administrator revealed the following: - Resident #1 tested positive first on 8/8/21; Resident #3 was roommates with Resident #1 (Resident #3 tested positive on 8/13/21) - Resident #2 tested positive on 8/13/21; Resident #5 was roommates with Resident #2 (Resident #5 tested positive on 8/18/21) - Resident #4 tested positive on 8/16/21; Resident #6 was roommates with Resident #4 (Resident #6 tested positive on 8/20/21) - Resident #7 tested positive on 9/20/21; Resident #11 was roommates with Resident #7 (Resident #11 tested positive on 9/24/21) - The Administrator also revealed that Resident #9 had been exposed to Covid 19 from her husband who tested positive and lives in the sister facility, within the same building. In an interview on 9/30/21 at 3:57 pm with the Administrator it was revealed the Administrator did not believe the facility had a break in infection control that contributed to 18 residents and 14 staff testing Covid positive since 8/8/21; the Administrator revealed he believed the spread of Covid 19 in the building was caused by visitation as he could not assure visitors always wore masks. Record review of list of residents on isolation revealed the following: - Resident #3 tested positive and was placed on isolation on 8/13/21 (5 days after known Covid 19 exposure from Resident#1), - Resident #5 tested positive and was placed on isolation 8/18/21 (5 days after known Covid 19 exposure from Resident #2), - Resident #6 tested positive and was placed on isolation on 8/20/21 (4 days after known Covid 19 exposure from Resident #4), - Resident #11 tested positive and was placed on isolation 9/24/21 (4 days after known Covid 19 exposure from Resident #7) - Resident #9 was not observed on the list (with known exposure from her husband). Record review of LTC respiratory surveillance line list for residents revealed the following: - Resident #7 had symptom onset 9/17/21 and positive Covid test collected on 9/20/21. - Resident #9 had positive Covid test collected on 9/24/21. In an interview on 10/3/21 at 10:00 am with the Administrator and the DON the Administrator was asked for clarification regarding previous statements that contract tracing showed the spread of Covid 19 in the building was caused by visitors, the Administrator did not provide an answer. The Administrator was also asked for clarification regarding Resident #3, Resident #5, Resident #6, and Resident #11's isolation date, Resident #9 having been put on isolation, as well as Resident #7 having symptoms as of 9/17/21 and did not receive Covid 19 test or isolation until 9/20/21; DON reported she made an error or typo in each instance . The DON went on to report that she added columns with the exact dates of isolation to the list of residents on isolation and that was when she made the documentation error. The DON did not provide clarification regarding Resident #9 not being placed on isolation. The Administrator did not provide further clarification regarding the reported errors or typos. Review of the COVID-19 Response Plan for nursing facilities version 4.0, dated 7/20/21, revealed - To Do's for Nursing Facilities . quarantine residents with prolonged close contact, or symptoms of Covid 19, regardless of vaccination status. - Control Measures for Residents . Isolation . any [exposed] roommates should be moved and monitored for fever and symptoms [at least 3 times daily] daily for 14 days, [per the CDC]. 3. In an interview on 9/30/21 at 12:50 pm with the DON revealed the facility does not have an infection prevention control policy, including a surveillance plan or Covid policies; the facility follows the Health and Human Services nursing facilities Covid response plan . In an interview on 9/30/21 at 1:41 pm with the Infection Control Nurse revealed the facility does not have a warm unit or any other designated location for residents while Covid 19 is ruled out. Infection Control Nurse reported the facility previously had a warm unit but now that residents are vaccinated, a warm unit was not needed. The Infection Control Nurse revealed the facility used to have a warm hall for unvaccinated residents; the facility does not currently have a warm hall. In an interview on 10/2/21 at 2:01 pm with the DON revealed a log of employee signs and symptoms of Covid 19 and call-ins were not kept because she would ask employees to get tested before returning to work. Record review of the COVID-19 Response Plan for nursing facilities version 4.0, dated 7/20/21, revealed: - To Do's for Nursing Facilities . A NF is not required to have a unit for residents who are Covid 19 positive or a unit for residents who have an unknown Covid 19 status at all times if the NF does not have any residents with unknown or positive status. Rather, the NF must have a response plan that includes cohorting plans with designated spaces for residents of each Covid 19 status (positive, negative, and unknown). Record review of facility's policy Coronavirus Disease (Covid 19) - Identification and Management of Ill Residents, revised July 2020, provided on 10/4/21, revealed residents who may have been exposed to someone with Covid 19 are monitored closely and not put with unexposed residents until 14 days after exposure 4. An observation on 9/30/21 at 1:40 pm revealed CNA N was sitting in the resident dining room with a N95 mask below her chin, not covering her nose and mouth. In an interview on 9/30/21 at 2:00 pm with CNA N revealed she was sitting in the dining room with her N95 mask below her chin. CNA N revealed the expectation of staff was to always wear N95 mask that covers the nose and mouth. An observation on 9/30/21 at 5:06 pm revealed Porter O with N95 mask below his chin, not covering nose and mouth, while talking on the phone in the library. In an interview on 9/30/21 at 5:20 pm with Porter O revealed he did have his N95 mask below his chin. Porter O revealed employees are expected to wear a mask the entire time they are in the facility; masks are used to protect himself and others. Porter O also revealed a risk of spreading Covid 19 if masks are not worn appropriately while in the facility. An observation on 10/1/21 at 2:38 pm revealed AD pushing a cart with snacks inside; AD failed to complete hand hygiene between giving residents snacks. In an interview on 10/1/21 2:40 pm with AD it was revealed the expectation was to complete hand hygiene anytime she comes in contact with a resident or their belongings. An observation on 10/1/21 at 2:46 pm revealed Dietary P did not complete hand hygiene before entering a resident room. In an interview on 10/1/21 at 2:46 pm with Dietary P revealed she did not complete hand hygiene before entering the resident room because she was only stepping inside to deliver a menu. Dietary P reported the expectation was to wash her hands constantly. In an interview on 9/30/21 at 8:41 am with the DON it was revealed all staff are expected to always wear a N95 mask that covers their nose and mouth. In an interview on 9/30/21 at 2:07 pm with the DON revealed staff members are expected to always wear N95 mask, that covers the nose and mouth, for the protection of the residents and staff. In an interview on 9/30/21 at 2:29 pm with the DON revealed staff know the expectation of always wearing a N95 mask through in-service training. The DON reported there was not a policy that states staff are to wear masks . Record Review of facility's policy Pandemic Disease, Prevention and Control, revised 3/26/2020, revealed staff will perform hand hygiene frequently, including before and after all resident contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves. Record review of the COVID-19 Response Plan for nursing facilities version 4.0, dated 7/20/21, revealed 6. To Do's for Nursing Facilities: In general. all staff should continue to wear source control while at work, per CMS and the CDC guidance . Staff who are caring for residents with COVID-19 or caring for residents in a building with widespread COVID-19 infection, should wear an N95 respirator and all CDC suggested PPE . PPE and Infection Control Education and Training - Ensure staff are educated and trained on which PPE they should use, proper procedure for donning (putting on) and doffing (taking off) PPE, and how to determine if the PPE is contaminated or damaged. NFs must identify whether the following concerns exist and specifically address them through education and training: On 10/4/21 at 2:29 pm the Administrator was notified an Immediate Jeopardy was identified and a Plan of Removal was requested. The IJ template was provided. The facility's Plan of Removal was accepted on 10/5/21 at 4:14 pm and reflected the following: [name of the facility] 10/4/21 Plan of removal: 1. Any person entering the community will be screened for COVID and s/s of COVID prior to entering the community by a trained employee. Every employee with be screened through the electronic Quixi system and visitors through paper log. The receptionist and/or designee at the entry points are trained to identify and screen all persons entering the community. a. The ED provided the training, to receptionist and designees, to ensure all persons entering by the community will be screened for s/s and exposure to COVID-19 and to document screenings. Training was completed on 10/04/21. b. The s/s will include questions of known close contact with a positive person. 2. Call log is in place where s/s are documented if any s/s and if any known positive exposure; implemented 10/4/21. As call-ins happen, they will be documented on the call-in log with documentation regarding s/s and positive exposure. a. The ED, DON & ADON are trained to ensure accuracy. The Nurse Consultant provided the training. b. The ED, DON or designee will monitor to ensure call log is completed and will identify possible exposures of staff, visitors, and residents. c. It will be monitored and audited in the daily stand-up meetings and contact tracing will be done for any positive exposures acknowledged on the call-in log. d. The surveillance documentation log has been updated to include date of onset or exposure and initiation of transmission-based precautions to eliminate date discrepancies. The log will be reviewed daily in the morning stand up meetings for accuracy. e. Any discrepancies in the surveillance documentation will be audited daily and the DON and IC Nurse are responsible for ensuring the accuracy of the log. This will be monitored and audited in the daily stand-up meetings by validating accuracy and any discrepancies will be immediately investigated to prevent future reoccurrence. 3. The infection control nurse and DON will accurately identify and monitor all contact tracing. a. The facility will mitigate the further spread of COVID-19 by following infection control policies, on-going in-servicing for all staff members for proper mask and hand hygiene, and contact tracing of all positive exposures. b. The infection control nurse and DON will monitor, and review daily and also identify any residents that need to be placed in isolation. c. Completed 10.04.2021 and in-servicing is on-going. 4. All residents with known positive exposure will be placed in isolation. a. Resident exposure is tracked by using the LTC Respiratory Surveillance Line List. The infection control nurse and DON will monitor to ensure this is completed daily. The DON and IC Nurse will monitor daily by reviewing in the morning stand up meetings. b. All current residents are monitored each shift for s/s and any known exposures. c. Current staff to be in-serviced and trained on identifying residents with s/s and known exposures on 10/4/21 and on-going by Infection Control Preventionist, DON, and ADON 5. The facility has a surveillance documentation policy in place identifying, tracking, monitoring and/or reporting infections. a. The infection control nurse will be in-serviced on infection control protocol to include surveillance documentation to identify, track, monitor/reporting of infections by nurse consultant by 10/4/21. b. Residents are identified from the surveillance documentation policy from the tracking and monitoring of infections. Once a resident is identified from the surveillance documentation policy by the IC Nurse, the clinical team will discuss in the daily morning stand-up meetings. c. All residents identified from the surveillance policy in place will have contact tracing performed by the IC Nurse, DON and/or ADON that have all been trained by the LSC Nurse Consultant on how to perform contact tracing. 6. In-services were completed by DON, ADON, Infection Control Nurse on appropriate N95 mask and hand hygiene on 10/04/21 and are on-going for all staff. Monitoring of the Plan of Removal included: Review of the facility's in-service records revealed: 1. On 9/30/21, 41 staff, and 10/5/21, 124 staff, were in-serviced for mandatory screening for employees and visitors to include signs and symptoms of Covid 19, exposure to Covid 19, and temperature. 2. On 10/4/21 the ED, DON, and ADON were in-serviced on the process for reviewing employees who call in sick including identification and follow up employees reporting signs and symptoms of Covid and or positive exposure to be documented in the call off log. 3. On 10/5/21 the DON, ADON, and Infection Control Nurse were in-serviced on contact tracing, including steps to be taken when a new case is identified including close contacts, extent of exposure, PPE utilized during potential exposure, and community response. 4. On 10/5/21, 123 staff, were in-serviced on identifying residents with signs and symptoms and known exposure as well as isolation precautions. 5. On 10/4/21 the Infection Control nurse was in-serviced regarding infection control, including practices for identifying, tracking, monitoring, reporting infections, as well as data analysis to rapid identification and response to potential outbreaks. 6. On 10/5/21, 124 staff, were in-serviced on infection control policies, Covid 19, masks, hand hygiene, and contact tracing. Interviews conducted on 10/6/21 from 8:54 am to 4:27 pm with staff from all three shifts, revealed staff were knowledgeable about infection control practices to include screening of all persons entering the building, hand hygiene, identifying signs and symptoms of Covid 19, as well as wearing masks properly. The ED and DON were knowledgeable about employee call-in log, screening, contact tracing. The interviewed staff included: Dietary P, Receptionist M, CNA S, LVN T, CMA U, Environmental Supervisor, LVN V, LVN W, Housekeeping X, CNA Y, CNA Z, Floater AA, ADON, Infection Control Nurse, DON, and administrator. In an interview on 10/6/21 at 4:27 pm with Administrator it was revealed that moving forward there is an employee call log for tracking employee call-ins and any employee that triggers (signs and symptoms of Covid 19, close exposure with someone known to be Covid 19 positive, or temperature) in the screening process. The employee call in log will be monitored, by Administrator or DON, during the facility morning stand up meeting. The Administrator also revealed the LTC respiratory surveillance list will be used to track respiratory illness; the LTC respiratory surveillance list will be monitored daily for accuracy. The Administrator also reported a resident is to be placed in isolation/quarantine if they have exposure to someone with Covid 19 as well as if contract tracing reveals close contact with a person who had signs and symptoms of Covid 19. An IJ was identified on 10/4/21. While the IJ was removed on 10/6/21, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for one (Resident #1) of six residents reviewed for neglect. 1. The DON failed to maintain delivery of the [MEDICATION NAME] maneuver to Resident #1, who began choking in the dining room on [DATE], until the object was dislodged and or the resident lost consciousness and required a different intervention. 2. DON, RN C, RN D and the ADON, who were CPR certified individuals, failed to correctly initiate Cardiopulmonary Resuscitation (CPR) for Resident #1 when she was identified as being unresponsive. Resident was transferred from the dining room to resident room while choking and then transferred to the bed with a backer board where her feet were hanging off the bed. Chest Compressions were not conducted correctly to be effective. DON placed a non-rebreather mask (a device used to deliver oxygen that requires the resident can breathe unassisted) on Resident #1 who was not breathing on their own at the time. By using the wrong type of oxygen delivery mask, the oxygen was not being delivered to the resident effectively. As a result of the facility's failures, the resident expired from the choking event on [DATE] with a cause of death, Asphyxia due to choking on food. An Immediate Jeopardy (IJ) was identified on [DATE]. Although, the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern due to needing to train staff and monitor their implementation of the Plan of Removal (POR). These failures could affect all 63 residents who could need the [MEDICATION NAME] maneuver or CPR by placing them at risk for aspiration and death. Findings Included: Review of Resident #1's undated face sheet reflected the resident was a [AGE] year old female who admitted to the facility on [DATE] and expired on [DATE]. The resident had [DIAGNOSES REDACTED]. The Face Sheet reported that Resident #1 was a full code. Resident #1's MDS assessment, dated [DATE], reported Resident #1 had clear speech and she was able to make herself understood and she understood others. The resident was cognitively impaired. She required extensive assistance from staff with bed mobility, transfers, and locomotion on unit, dressing, and toilet use. She required limited assistance from staff with eating and personal hygiene. Resident #1 used a wheelchair for mobility. The MDS reported that Resident #1 only required setup or clean-up assistance with eating. The MDS reported that Resident #1 exhibited swallowing disorder symptoms of coughing or choking during meals or when swallowing medications. Resident #1 had a mechanically altered diet. The MDS reported that resident received speech therapy, occupational therapy, and physical therapy. Review of Resident #1's SLP Evaluation and Plan of Treatment, dated [DATE], reported that it was recommended that the resident receive Mechanical Soft Textured diet and thin liquids, and that she receive close supervision for oral intake. The evaluation revealed mild oral, likely pharyngeal weakness affecting her ability to safely swallow. It reported that the resident was at risk for aspiration and skilled SLP services for dysphagia were warranted to assess/evaluate the least restrictive oral intake, minimize aspiration/risk of and instruct family/staff in compensation techniques in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs and safely consume highest level of oral intake. Review of Resident #1's Speech Therapy Treatment Encounter Notes, dated [DATE] reflected: Patient (Resident 1) saw at beginning of lunchtime meal. Patient on mechanical soft solids and thin liquids via cup rim. Patient drank thin liquid via cup rim during meal with x1 immediate cough. Patient with disorganized and delayed mastication, along with L (left) side pocketing and residue. A Speech Therapy Note dated [DATE] reflected: Medications were administered whole with difficulty swallowing. Pt (Resident #1) ended up chewing medication, pills given in applesauce with improved swallow function, however, continued to chew larger meds. Nursing advised to crush meds in puree. Review of Resident #1's Progress Notes, dated [DATE] and written by the DON, reported The resident was seen eating lunch, up on her wheelchair. She ate 75% of lunch served. As the resident was wheeling herself away from the table, she stopped I noticed her stoic with eyes wide open. At that time, I ran to her, while the CNA closer to her immediately started the [MEDICATION NAME] maneuver. Asked if she was ok, no response noted. I swept her mouth for visible food particle, but the resident tried to bite. She (resident) was wheeled to her room by the staff, and 911 was called. No pulse felt, resident was unresponsive, CPR started. Suctioning initiated. CPR continued till paramedics arrived, at about 13:06 (1:06pm) and they took over. Review of Resident #1's Progress Notes, dated [DATE] at 16:31(4:31pm) by LVN A revealed residents' family member arrived at the facility and notified staff that resident had expired. Review of local county medical examiner report revealed Resident #1 time of death was [DATE] at 1:32PM. Cause of death is listed as Asphyxia Due to: Choking (FOOD). Review of local fire department Patient Care Record dated [DATE] revealed dispatch notified at 12:53PM of resident choking. EMS arrived at 1:01PM. Narrative: Medic was dispatched to a choking persons a call and arrived to find [AGE] year old female in [MEDICAL CONDITION] with CPR in progress. Upon arrival the patient was found lying in her nursing home facility bed unconscious and unresponsive, with her legs hanging off the end of the bed. The facilities staff was performing poor quality CPR and found holding a non-rebreather over the patients mouth flowing at 151pm. Manual chest compressions were initiated by paramedic at the time of making patient contact .The patients airway was inspected using a mac 3 blade by paramedic and a pellet of chewed carrots approximately 6cm in length and 2cm in diameter was removed from the patients airway using Magill forceps. An intubation attempt was performed as indicated above. Upon initiating respirations food had immediately begun to come up the intubation tube, suction was the initiated to attempt to remove the foreign objects. Phone interview with Paramedic on [DATE] at 1:27PM stated he was one of several responders to the [DATE] call involving Resident #1. He stated he entered Resident #1's room, and saw resident lying in bed with a backer board under her and her feet hanging off the bed. He stated there was one worker doing some CPR and another worker holding an incorrect bag over resident's mouth intended for oxygen. Paramedic stated he considered the CPR that had been delivered to Resident #1 as poor because the staff's form was not correct. He stated the staff appeared afraid to hurt resident and that she was not doing deep chest compressions. Paramedic stated that his Lieutenant removed what appeared to be a pretty solid chewed up carrots about the size of a thumb out of resident's airway. He stated the carrots were pressed baby carrots and were solid in form to where they were solid enough to stick to the forceps like a fork and remain solid through removal. He stated if the carrots were chewed up enough or a mechanical soft texture it would have been able to be mashed up upon removal but stated the carrots were solid. Paramedic stated he was not aware that Resident #1 was moved from the dining room to her room and that in his judgement resident should have not been moved and emergency services should have been done on site. Review of hospital provider notes dated [DATE] revealed HPI: Pt (Resident) was eating lunch when she choked and collapsed. CPR was started on scene. EMR arrived at 1308 (1:08pm) and pt was asystole (cardiac standstill or absence of heartbeat). CPR started by EMS. Pt (Resident) received aminophylline, [MEDICATION NAME] x2, and EPI. Pt was intubated en route. Review of Resident #1 Progress Note dated [DATE] reported resident's daughter in facility to pick up resident belonging, states resident has expired. In an interview with the ADON on [DATE] at 3:29 PM, she stated that Resident #1's family came to the facility after 2:00 PM, but before 5:00 PM. The ADON stated it was 2 women and a man; one of the two women was identified as the resident's daughter. The ADON stated the daughter asked her and RN D what Resident #1 had choked on. The ADON stated that they were unsure and did not know what the resident had eaten, so they went and asked Resident #1's table mate who told them she had only eaten two bites of carrots during that meal. Review of Provider Investigation Report dated [DATE] signed by the Administrator revealed the incident occurred on [DATE] at approximately 1:00PM when Resident #1 was found to be choking in the dining room where the [MEDICATION NAME] Maneuver was performed and resident became unresponsive. The facility did not report the incident to the state agency until three days after the incident occurred when the medical examiner confirmed cause of death to be asphyxia due to choking (FOOD). The report revealed the incident was not reported on the original date of death due to choking because clinical management at the time of transport to the ER, that Resident #1 had experienced a medical change in condition rather than choking. Review of the Menu for Friday, [DATE] reflected Baked fish Florentine, Seasoned red potatoes, parslied baby carrots, bread or roll and butter or margarine. The alternate meal was Swedish meatballs with gravy, red potatoes, parslied baby carrots, bread or roll and butter or margarine and banana cream pie with choice of beverage. Interview with CNA E on [DATE] at 1:25 PM revealed that she worked and responded to the choking incident for Resident #1 on [DATE]. CNA E stated that Resident #1 was eating (what she was eating was unknown) and right in the middle of her eating, CNA E noticed that Resident #1 started self-propelling herself in her wheelchair away from the table. CNA E approached the resident and asked if she needed anything but the resident did not respond and started waiving her hands towards her neck. CNA E stated that she asked the resident if she was choking and the resident nodded yes. CNA E stated that she then got the resident out of her wheelchair with the help of the resident and she started the [MEDICATION NAME] maneuver and yelled for help. CNA E stated that the DON responded to her call of help and the DON took over the [MEDICATION NAME]. CNA E stated that the DON was doing the [MEDICATION NAME] maneuver and she noticed that the DON put the resident back into her wheelchair. CNA E stated that the resident was fighting for air whenever the DON wheeled the resident into her room from out of the dining room. CNA E stated that she knew Resident #1 was fighting for air because she was still waving her hands towards her neck. In an interview with RN C on [DATE] at 2:10 PM, RN C stated that she was at the nurses' station charting when she heard and saw staff running towards Resident #1. She stated that she saw CNA E doing the [MEDICATION NAME] maneuver and the DON swept Resident #1's mouth, but food was not found. RN C stated that she heard the DON state she was bitten, and at that time Resident #1 was sat back into her wheelchair by the DON and wheeled to Resident #1's room. RN C stated that she knew Resident #1 was choking because her eyes were bulging and she was shaking her head yes. RN C stated that she noticed Resident #1 was not responsive whenever the resident was transferred from her wheelchair to the bed, and that the DON stated that the resident did not have a pulse and or breathing. RN C stated that CPR was started by the DON and Dietary Aide because the Dietary Aide was closest to the resident to start chest compressions. Dietary Aide provided the first round of chest compressions, and the next rounds were by RN C, then RN D and then the ADON until EMS arrived. RN C stated that best practice was to start CPR on the spot and not to move the resident because the quicker CPR is started, the better the survival rate. Interview with CNA B on [DATE] at 2:27 PM stated that she was in the dining room feeding a resident whenever she heard CNA E yelling Resident #1 was choking. CNA B stated that the DON took over the [MEDICATION NAME] and the DON put her hand in the resident's mouth where she was bitten. At that point, the resident was sat down in her wheelchair where she sat gasping for air, still choking. CNA B stated the resident was pushed to her room. In an interview with the ADON on [DATE] at 3:29 PM, she stated that she was on the B-side of the dining room whenever she heard staff yelling, She's choking!, and she then ran over and saw the DON sweeping Resident #1's mouth. She then noticed that Resident #1 was biting down and she heard a nurse say, Let's take the resident to her room, from the middle of the dining room. The ADON stated that the resident was still choking whenever she was put back into her wheelchair because her eyes were open and she was gasping for air. The ADON stated that the [MEDICATION NAME] should not have been stopped until the item came up and or the resident lost consciousness. ADON stated Resident #1 was transferred to her bed by herself, Dietary Aide, RN D, CNA B, and RN C and that at that time, resident was not responsive. The ADON stated that the DON checked for a pulse and breathing, and that there was none. The ADON stated that someone had gotten the crash cart that had emergency supplies on it, and one of those supplies was a back board that was needed so it could be placed under the resident to start CPR. The ADON stated that CPR was initiated by the DON and a Dietary Aide, and chest compressions were then completed by RN C, herself, and then another employee, whom she was unable to recall, until EMS arrived. In an interview with the DON on [DATE] at 2:49 PM, she stated that she was in the dining room feeding and eating with a resident whenever she heard CNA E yelling for help. She then ran over to Resident #1 and started a mouth sweep where she could not get in her mouth because the resident was biting down. The DON stated that she then started the [MEDICATION NAME] maneuver and tried to do another mouth sweep and the resident bit down on her finger. At that time resident was sat back down in her wheelchair. DON stated that Resident #1 was still choking whenever she was sat back down in her chair but was changing in color. The DON stated that she stopped the [MEDICATION NAME] because it was painful and hurt really bad whenever the resident bit her, and that she thought another staff had started the [MEDICATION NAME], but did not know because she left to the nurse's station to call [DATE]. DON stated the call to Emergency Services lasted a little over one minute, but no more than two minutes. She then went to Resident #1's room where the resident had been transferred to her bed. The DON stated that whenever she went to the room, she saw Dietary Aide doing chest compressions. The DON stated that she went checked Resident #1 for a pulse and for breathing, and she stated that resident did not have either. The DON stated that she got a breather bag and placed it over resident's mouth to provide oxygen while the Dietary Aide did chest compressions. The DON stated that she only provided oxygen to the resident while staff (DON was unable to recall all the staff who helped and in what order) did chest compressions. The DON stated that the resident was moved to her room for safety, and she knew they would need to do suctioning and there were no wall outlets where the resident started choking at. A joint interview on [DATE] at 1:23 PM with SLPI F and SLPI G reported that Resident #1 required close supervision with meals. SLPI F defined close supervision as one-on-one supervision while the resident ate all meals. Staff reported that anytime a resident was at risk for aspiration, it was identified on the physician orders [REDACTED]. The identified intervention was close supervision, safe swallowing techniques and checking for pocketing. SLPI G looked at Resident #1's electronic chart and stated that there were no orders for aspiration precautions in her chart, and there should have been one. In an interview with Dietary Aide A on [DATE] at 9:05 AM, she stated that she was serving in the kitchen near the nurse's station whenever she saw Resident #1 eating carrots. Dietary Aide stated that Resident #1 was served a mechanical soft diet of carrots and meatballs with gravy. Dietary Aide stated that after the incident, she observed the plate and noticed that the resident only ate a few carrots. Dietary Aide stated that she heard staff yelling and saw some running towards Resident #1. She stated that she saw the DON helping the resident by doing the [MEDICATION NAME] maneuver, and the DON put her finger into the resident's mouth, and the resident bit down on the DON's finger. The resident was then placed back into her wheelchair. Dietary Aide stated that Resident #1's, eyes were rolling back and that she acted like she could not breathe, and then everyone rolled resident in her wheelchair back to her room. Dietary Aide stated that she helped other staff put the resident in her bed, and while they were putting her in the bed she was still acting as if she could not breathe. Dietary Aide stated that the DON went to get oxygen for the resident and other items that she was unsure what they were called. Dietary Aide stated that she had gotten two paper towels to put over the resident's mouth to create a barrier. She stated that the resident had saliva coming out of her mouth, and that she just wanted to help the resident because she knew the resident was not responsive. So she tilted the resident's head back and pinched her nose and gave resident ,[DATE] breaths, provided chest pumps, and then the DON came back into the room. Dietary Aide stated that she wiped resident's mouth and she heard the DON say the resident was not responsive, so the DON put a mask over the resident's mouth and then Dietary Aide gave a round of chest compressions. Someone else then started giving chest pumps while the DON gave the resident oxygen. Dietary Aide stated that there were nurses in the room, but she just wanted to save the resident's life because everyone was helping with something. She said she was not trained and or certified to provide CPR, and that she was trying to help resident. Dietary Aide stated that she was unsure how long it took for CPR to get started or who was in the room at that time. In an interview with RN D on [DATE] at 1:46 PM, she stated that that she was on the phone whenever she heard someone yelling for help. RN D stated that she went with other staff to Resident #1's room to see what she could help with, and that she helped staff transfer the resident from her wheelchair to her bed. At that point, Resident #1 was unresponsive, and that she knew she was because once the resident was on the bed, RN D called the resident by name she touched, and shook resident, but there was no response from her. RN D stated that followed by that, the DON entered into the room and checked the resident's pulse and to see if she was breathing, and there was nothing noted. RN D stated that CPR was started by Dietary Aide and the DON. She stated the DON provided oxygen to the resident while tilting the resident's head back, and the Dietary Aide did chest compressions. RN D stated that Dietary Aide did CPR first because she was closest to resident. RN D stated that CPR was started within two minutes of the resident becoming unresponsive. RN D stated that CPR should have been done on site in the dining room and the resident should have not been moved to her room. In an interview with the ED on [DATE] at 6:24 PM, he stated that his clinical department responded to Resident #1 appropriately. The ED stated that although the resident was moved from the dining room to her room, he was informed that an unresponsive person can go up to five minutes without CPR before damages can occur. The ED stated that he paced it himself, and where the incident happed to Resident #1's room location was only ,[DATE] steps. He stated that he did not account for how long it took staff to transfer resident to her bed and to get back board under her. ED stated that the process his staff took he considered it an immediate response. Review of Resident Council Minutes, dated [DATE], reported vegetables sometimes too hard to chew. There was no subsequent Resident Council Minutes. There was no documentation that issue was addressed by the facility. Review of Emergency Procedure for Choking, dated [DATE], reflected the following: .4. Call for help, but stay with the resident. .5. Quickly assure the resident that you are going to stay and assist him or her. .6. If the resident cannot cough, only then should abdominal thrusts be performed . .h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Review of A step-by-step guide explaining what to do in a choking emergency, obtained on [DATE] from https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637, reflected the following: To clear the airway of an unconscious person: Lower the person on his or her back onto the floor, arms to the side. Clear the airway. If a blockage is visible at the back of the throat or high in the throat, reach a finger into the mouth and sweep out the cause of the blockage. Don't try a finger sweep if you can't see the object. Be careful not to push the food or object deeper into the airway, which can happen easily in young children. Begin CPR if the object remains lodged and the person doesn't respond after you take the above measures. The chest compressions used in CPR may dislodge the object. Remember to recheck the mouth periodically. Review of Policy Emergency Procedure-Cardiopulmonary Resuscitation, dated [DATE], reported the following: .5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. .6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. .8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advances Life Support (ALS). .9. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: .a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exits for that individual; or .b. There are obvious signs of irreversible death. Review of Abuse and Neglect - Assessment and Recognition dated [DATE] revealed Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Any suspected or substantiated incidents of . neglect of the residents is immediately reported to the Administration and appropriate state government and city agencies. Review of Abuse and Neglect Clinical Protocol dated [DATE] revealed The staff and practitioners will investigate possible occurrences of abuse and neglect to clarify what happened and identify causes. The facility management and staff will comply with applicable laws and regulations pertaining to the documentation and management of abuse and neglect. An Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:17 PM. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 2:58 PM. The Plan of Removal reflected: In their discussion with the facility, HHSC stated alleged that the facility created an Immediate Jeopardy condition by: 1. The facility discontinued the [MEDICATION NAME] Maneuver after 2 unsuccessful attempts to dislodge food that the resident was choking on. Company Policy and Procedure dictates that the maneuver continue until either the foreign object is dislodged, or until the person becomes unconscious. 2. Initial CPR was begun by a Dietary Aide who is not certified on CPR despite multiple nurses and nurse aides being present in the room. The facility identified the following residents as being at risk of aspiration; Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8. All resident records have been audited to identify any other residents at risk for aspiration. None were found. This audit was completed immediately [DATE] by facility ADON. These residents were identified from the eMar based on a [DIAGNOSES REDACTED]. .The first step the facility will take to remove the immediacy, will be to inservice all clinical and dietary staff currently at the facility, including the DON, on the P&P (policy and procedure) regarding continuing the [MEDICATION NAME] Maneuver until the resident has passed out or until the foreign object is removed. This inservice is currently being done by (RN I), and (Senior Nurse Consultant) for (the facility). Any PRN staff or any staff currently on leave will be inserviced prior to returning to work. Competency drills will be done on medical emergency response drills, (cardiac and respiratory), weekly times 4 and monthly times 3. Drills will be monitored by the regional nurse. The drills will be evaluated for staff performance with appropriate counseling and retaining as needed. Inservices on Abuse and Neglect will be conducted by Executive Director or designee. Source documentation will be Abuse/Neglect Policies and Procedures. This training will include all facility staff. The facility will validate CPR and [MEDICATION NAME] competency via return demonstration with all licensed staff, whether currently certified or not. This will begin taking place on-site on [DATE] by certified BLS trainers from outside (the facility). Anticipated completion [DATE]. Clinical staff will not be allowed to provide care for any of the above identified at-risk residents until they have attended the inservice. CPR will only be done by staff who are certified. For purposes of this plan, only licensed clinical staff will participate in the competency testing. The seven residents identified as being at risk will be observed during meal service by licensed nurses, for signs of aspiration. The food service supervisor will monitoring food service to make sure that those seven residents' modified diets are served as ordered by physician. The food service manager will submit weekly reports of observations. No licensed staff will be allowed to work until their CPR certification is verified. Dietary staff have been instructed not to do CPR. The facility will immediately add a note to each med cart of the residents at risk for aspiration. This was done on [DATE]. An alert will be added to the eMar for every resident on the list for at risk for aspiration precautions. This was done [DATE]. Monitoring interviews were conducted at various times on [DATE] with staff the following staff: CNA E, CNA F, CAN G, CNA H, CNA J, CNA B, CNA K, LVN L, LVN M, RN D, RN N, DON, ADON, RN M. Staff interviewed were representative of various facility shifts. Staff was able to provide return demonstration and competency regarding training over the [MEDICATION NAME] Maneuver and CPR and competency regarding abuse and neglect. CMS Form 672 signed and dated by the DON on [DATE] revealed resident census of 63.

Based on interview and record review, the facility failed to develop and implement written polices and procedures that prohibit and prevent the neglect of residents for one (Resident #1) of six residents reviewed neglect. 1. The Administrator failed to implement the facility's written policies and procedures that prohibit and prevent neglect of residents. The Administrator failed to thoroughly investigate the death of Resident #1. The Administrator failed to report the death of Resident #1 to the state agency within the given timeframe. 2. The DON failed to maintain delivery of the [MEDICATION NAME] maneuver to Resident #1, who began choking in the dining room on [DATE], until the object was dislodged and or the resident lost consciousness and required a different intervention. 3. DON, RN C, RN D and the ADON, who were CPR certified individuals, failed to correctly initiate Cardiopulmonary Resuscitation (CPR) for Resident #1 when she was identified as being unresponsive. Resident was transferred from the dining room to resident room while choking and then transferred to the bed with a backer board where her feet were hanging off the bed. Chest Compressions were not conducted correctly to be effective. DON placed a non-rebreather mask (a device used to deliver oxygen that requires the resident can breathe unassisted) on Resident #1 who was not breathing on their own at the time. By using the wrong type of oxygen delivery mask, the oxygen was not being delivered to the resident effectively. As a result of the facility's failures, the resident expired from the choking event on [DATE] with a cause of death, Asphyxia due to choking on food. An Immediate Jeopardy (IJ) was identified on [DATE]. Although, the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern due to needing to train staff and monitor their implementation of the Plan of Removal (POR). These failures could affect all 63 residents who could need the [MEDICATION NAME] maneuver or CPR by placing them at risk for aspiration and death. Findings Included: Review of Abuse and Neglect - Assessment and Recognition dated [DATE] revealed Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Any suspected or substaniated incidents of . neglect of the residents is immediatly reported to the Administration and pparopriate state government and city agencies. Review of Abuse and Neglect Clinical Protocol dated [DATE] revaled The staff and pacticiioners will invesigate possible occurances of abuse and neglect to clairfy what happened and identify causes. The facility management and staff will comply with applicabale laws and regulations pertaining to the documentation and management of abuse and neglect. Review of Resident #1's undated face sheet reflected the resident was a [AGE] year old female who admitted to the facility on [DATE] and expired on [DATE]. The resident had [DIAGNOSES REDACTED]. The Face Sheet reported that Resident #1 was a full code. Resident #1's MDS assessment, dated [DATE], reported Resident #1 had clear speech and she was able to make herself understood and she understood others. The resident was cognitively impaired. She required extensive assistance from staff with bed mobility, transfers, and locomotion on unit, dressing, and toilet use. She required limited assistance from staff with eating and personal hygiene. Resident #1 used a wheelchair for mobility. The MDS reported that Resident #1 only required setup or clean-up assistance with eating. The MDS reported that Resident #1 exhibited swallowing disorder symptoms of coughing or choking during meals or when swallowing medications. Resident #1 had a mechanically altered diet. The MDS reported that resident received speech therapy, occupational therapy, and physical therapy. Review of Resident #1's SLP Evaluation and Plan of Treatment, dated [DATE], reported that it was recommended that the resident receive Mechanical Soft Textured diet and thin liquids, and that she receive close supervision for oral intake. The evaluation revealed mild oral, likely pharyngeal weakness affecting her ability to safely swallow. It reported that the resident was at risk for aspiration and skilled SLP services for dysphagia were warranted to assess/evaluate the least restrictive oral intake, minimize aspiration/risk of and instruct family/staff in compensation techniques in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs and safely consume highest level of oral intake. Review of Resident #1's Speech Therapy Treatment Encounter Notes, dated [DATE] reflected: Patient (Resident 1) saw at beginning of lunchtime meal. Patient on mechanical soft solids and thin liquids via cup rim. Patient drank thin liquid via cup rim during meal with x1 immediate cough. Patient with disorganized and delayed mastication, along with L (left) side pocketing and residue. A Speech Therapy Note dated [DATE] reflected: Medications were administered whole with difficulty swallowing. Pt (Resident #1) ended up chewing medication, pills given in applesauce with improved swallow function, however, continued to chew larger meds. Nursing advised to crush meds in puree. Review of Resident #1's Progress Notes, dated [DATE] and written by the DON, reported The resident was seen eating lunch, up on her wheelchair. She ate 75% of lunch served. As the resident was wheeling herself away from the table, she stopped I noticed her stoic with eyes wide open. At that time, I ran to her, while the CNA closer to her immediately started the [MEDICATION NAME] maneuver. Asked if she was ok, no response noted. I swept her mouth for visible food particle, but the resident tried to bite. She (resident) was wheeled to her room by the staff, and 911 was called. No pulse felt, resident was unresponsive, CPR started. Suctioning initiated. CPR continued till paramedics arrived, at about 13:06 (1:06pm) and they took over. Review of Resident #1's Progress Notes, dated [DATE] at 16:31(4:31pm) by LVN A revealed residents' family member arrived at the facility and notified staff that resident had expired. Review of local county medical examiner report revealed Resident #1 time of death was [DATE] at 1:32PM. Cause of death is listed as Asphyxia Due to: Choking (FOOD). Review of local fire department Patient Care Record dated [DATE] revealed dispatch notified at 12:53PM of resident choking. EMS arrived at 1:01PM. Narrative: Medic was dispatched to a choking persons a call and arrived to find [AGE] year old female in [MEDICAL CONDITION] with CPR in progress. Upon arrival the patient was found lying in her nursing home facility bed unconscious and unresponsive, with her legs hanging off the end of the bed. The facilities staff was performing poor quality CPR and found holding a non-rebreather over the patients mouth flowing at 151pm. Manual chest compressions were initiated by paramedic at the time of making patient contact .The patients airway was inspected using a mac 3 blade by paramedic and a pellet of chewed carrots approximately 6cm in length and 2cm in diameter was removed from the patients airway using Magill forceps. An intubation attempt was performed as indicated above. Upon initiating respirations food had immediately begun to come up the intubation tube, suction was the initiated to attempt to remove the foreign objects. Phone interview with Paramedic on [DATE] at 1:27PM stated he was one of several responders to the [DATE] call involving Resident #1. He stated he entered Resident #1's room, and saw resident lying in bed with a backer board under her and her feet hanging off the bed. He stated there was one worker doing some CPR and another worker holding an incorrect bag over resident's mouth intended for oxygen. Paramedic stated he considered the CPR that had been delivered to Resident #1 as poor because the staff's form was not correct. He stated the staff appeared afraid to hurt resident and that she was not doing deep chest compressions. Paramedic stated that his Lieutenant removed what appeared to be a pretty solid chewed up carrots about the size of a thumb out of resident's airway. He stated the carrots were pressed baby carrots and were solid in form to where they were solid enough to stick to the forceps like a fork and remain solid through removal. He stated if the carrots were chewed up enough or a mechanical soft texture it would have been able to be mashed up upon removal but stated the carrots were solid. Paramedic stated he was not aware that Resident #1 was moved from the dining room to her room and that in his judgement resident should have not been moved and emergency services should have been done on site. Review of hospital provider notes dated [DATE] revealed HPI: Pt (Resident) was eating lunch when she choked and collapsed. CPR was started on scene. EMR arrived at 1308 (1:08pm) and pt was asystole (cardiac standstill or absence of heartbeat). CPR started by EMS. Pt (Resident) received aminophylline, [MEDICATION NAME] x2, and EPI. Pt was intubated en route. Review of Resident #1 Progress Note dated [DATE] reported resident's daughter in facility to pick up resident belonging, states resident has expired. In an interview with the ADON on [DATE] at 3:29 PM, she stated that Resident #1's family came to the facility after 2:00 PM, but before 5:00 PM. The ADON stated it was 2 women and a man; one of the two women was identified as the resident's daughter. The ADON stated the daughter asked her and RN D what Resident #1 had choked on. The ADON stated that they were unsure and did not know what the resident had eaten, so they went and asked Resident #1's table mate who told them she had only eaten two bites of carrots during that meal. Review of Provider Investigation Report dated [DATE] signed by the Administrator revealed the incident occurred on [DATE] at approximately 1:00PM when Resident #1 was found to be choking in the dining room where the [MEDICATION NAME] Maneuver was performed and resident became unresponsive. The facility did not report the incident to the state agency until three days after the incident occurred when the medical examiner confirmed cause of death to be asphyxia due to choking (FOOD). The report revealed the incident was not reported on the original date of death due to choking because clinical management at the time of transport to the ER, that Resident #1 had experienced a medical change in condition rather than choking. Review of the Menu for Friday, [DATE] reflected Baked fish Florentine, Seasoned red potatoes, parslied baby carrots, bread or roll and butter or margarine. The alternate meal was Swedish meatballs with gravy, red potatoes, parslied baby carrots, bread or roll and butter or margarine and banana cream pie with choice of beverage. Interview with CNA E on [DATE] at 1:25 PM revealed that she worked and responded to the choking incident for Resident #1 on [DATE]. CNA E stated that Resident #1 was eating (what she was eating was unknown) and right in the middle of her eating, CNA E noticed that Resident #1 started self-propelling herself in her wheelchair away from the table. CNA E approached the resident and asked if she needed anything but the resident did not respond and started waiving her hands towards her neck. CNA E stated that she asked the resident if she was choking and the resident nodded yes. CNA E stated that she then got the resident out of her wheelchair with the help of the resident and she started the [MEDICATION NAME] maneuver and yelled for help. CNA E stated that the DON responded to her call of help and the DON took over the [MEDICATION NAME]. CNA E stated that the DON was doing the [MEDICATION NAME] maneuver and she noticed that the DON put the resident back into her wheelchair. CNA E stated that the resident was fighting for air whenever the DON wheeled the resident into her room from out of the dining room. CNA E stated that she knew Resident #1 was fighting for air because she was still waving her hands towards her neck. In an interview with RN C on [DATE] at 2:10 PM, RN C stated that she was at the nurses' station charting when she heard and saw staff running towards Resident #1. She stated that she saw CNA E doing the [MEDICATION NAME] maneuver and the DON swept Resident #1's mouth, but food was not found. RN C stated that she heard the DON state she was bitten, and at that time Resident #1 was sat back into her wheelchair by the DON and wheeled to Resident #1's room. RN C stated that she knew Resident #1 was choking because her eyes were bulging and she was shaking her head yes. RN C stated that she noticed Resident #1 was not responsive whenever the resident was transferred from her wheelchair to the bed, and that the DON stated that the resident did not have a pulse and or breathing. RN C stated that CPR was started by the DON and Dietary Aide because the Dietary Aide was closest to the resident to start chest compressions. Dietary Aide provided the first round of chest compressions, and the next rounds were by RN C, then RN D and then the ADON until EMS arrived. RN C stated that best practice was to start CPR on the spot and not to move the resident because the quicker CPR is started, the better the survival rate. Interview with CNA B on [DATE] at 2:27 PM stated that she was in the dining room feeding a resident whenever she heard CNA E yelling Resident #1 was choking. CNA B stated that the DON took over the [MEDICATION NAME] and the DON put her hand in the resident's mouth where she was bitten. At that point, the resident was sat down in her wheelchair where she sat gasping for air, still choking. CNA B stated the resident was pushed to her room. In an interview with the ADON on [DATE] at 3:29 PM, she stated that she was on the B-side of the dining room whenever she heard staff yelling, She's choking!, and she then ran over and saw the DON sweeping Resident #1's mouth. She then noticed that Resident #1 was biting down and she heard a nurse say, Let's take the resident to her room, from the middle of the dining room. The ADON stated that the resident was still choking whenever she was put back into her wheelchair because her eyes were open and she was gasping for air. The ADON stated that the [MEDICATION NAME] should not have been stopped until the item came up and or the resident lost consciousness. ADON stated Resident #1 was transferred to her bed by herself, Dietary Aide, RN D, CNA B, and RN C and that at that time, resident was not responsive. The ADON stated that the DON checked for a pulse and breathing, and that there was none. The ADON stated that someone had gotten the crash cart that had emergency supplies on it, and one of those supplies was a back board that was needed so it could be placed under the resident to start CPR. The ADON stated that CPR was initiated by the DON and a Dietary Aide, and chest compressions were then completed by RN C, herself, and then another employee, whom she was unable to recall, until EMS arrived. In an interview with the DON on [DATE] at 2:49 PM, she stated that she was in the dining room feeding and eating with a resident whenever she heard CNA E yelling for help. She then ran over to Resident #1 and started a mouth sweep where she could not get in her mouth because the resident was biting down. The DON stated that she then started the [MEDICATION NAME] maneuver and tried to do another mouth sweep and the resident bit down on her finger. At that time resident was sat back down in her wheelchair. DON stated that Resident #1 was still choking whenever she was sat back down in her chair but was changing in color. The DON stated that she stopped the [MEDICATION NAME] because it was painful and hurt really bad whenever the resident bit her, and that she thought another staff had started the [MEDICATION NAME], but did not know because she left to the nurse's station to call [DATE]. DON stated the call to Emergency Services lasted a little over one minute, but no more than two minutes. She then went to Resident #1's room where the resident had been transferred to her bed. The DON stated that whenever she went to the room, she saw Dietary Aide doing chest compressions. The DON stated that she went checked Resident #1 for a pulse and for breathing, and she stated that resident did not have either. The DON stated that she got a breather bag and placed it over resident's mouth to provide oxygen while the Dietary Aide did chest compressions. The DON stated that she only provided oxygen to the resident while staff (DON was unable to recall all the staff who helped and in what order) did chest compressions. The DON stated that the resident was moved to her room for safety, and she knew they would need to do suctioning and there were no wall outlets where the resident started choking at. A joint interview on [DATE] at 1:23 PM with SLPI F and SLPI G reported that Resident #1 required close supervision with meals. SLPI F defined close supervision as one-on-one supervision while the resident ate all meals. Staff reported that anytime a resident was at risk for aspiration, it was identified on the physician orders [REDACTED]. The identified intervention was close supervision, safe swallowing techniques and checking for pocketing. SLPI G looked at Resident #1's electronic chart and stated that there were no orders for aspiration precautions in her chart, and there should have been one. In an interview with Dietary Aide A on [DATE] at 9:05 AM, she stated that she was serving in the kitchen near the nurse's station whenever she saw Resident #1 eating carrots. Dietary Aide stated that Resident #1 was served a mechanical soft diet of carrots and meatballs with gravy. Dietary Aide stated that after the incident, she observed the plate and noticed that the resident only ate a few carrots. Dietary Aide stated that she heard staff yelling and saw some running towards Resident #1. She stated that she saw the DON helping the resident by doing the [MEDICATION NAME] maneuver, and the DON put her finger into the resident's mouth, and the resident bit down on the DON's finger. The resident was then placed back into her wheelchair. Dietary Aide stated that Resident #1's, eyes were rolling back and that she acted like she could not breathe, and then everyone rolled resident in her wheelchair back to her room. Dietary Aide stated that she helped other staff put the resident in her bed, and while they were putting her in the bed she was still acting as if she could not breathe. Dietary Aide stated that the DON went to get oxygen for the resident and other items that she was unsure what they were called. Dietary Aide stated that she had gotten two paper towels to put over the resident's mouth to create a barrier. She stated that the resident had saliva coming out of her mouth, and that she just wanted to help the resident because she knew the resident was not responsive. So she tilted the resident's head back and pinched her nose and gave resident ,[DATE] breaths, provided chest pumps, and then the DON came back into the room. Dietary Aide stated that she wiped resident's mouth and she heard the DON say the resident was not responsive, so the DON put a mask over the resident's mouth and then Dietary Aide gave a round of chest compressions. Someone else then started giving chest pumps while the DON gave the resident oxygen. Dietary Aide stated that there were nurses in the room, but she just wanted to save the resident's life because everyone was helping with something. She said she was not trained and or certified to provide CPR, and that she was trying to help resident. Dietary Aide stated that she was unsure how long it took for CPR to get started or who was in the room at that time. In an interview with RN D on [DATE] at 1:46 PM, she stated that that she was on the phone whenever she heard someone yelling for help. RN D stated that she went with other staff to Resident #1's room to see what she could help with, and that she helped staff transfer the resident from her wheelchair to her bed. At that point, Resident #1 was unresponsive, and that she knew she was because once the resident was on the bed, RN D called the resident by name she touched, and shook resident, but there was no response from her. RN D stated that followed by that, the DON entered into the room and checked the resident's pulse and to see if she was breathing, and there was nothing noted. RN D stated that CPR was started by Dietary Aide and the DON. She stated the DON provided oxygen to the resident while tilting the resident's head back, and the Dietary Aide did chest compressions. RN D stated that Dietary Aide did CPR first because she was closest to resident. RN D stated that CPR was started within two minutes of the resident becoming unresponsive. RN D stated that CPR should have been done on site in the dining room and the resident should have not been moved to her room. In an interview with the ED on [DATE] at 6:24 PM, he stated that his clinical department responded to Resident #1 appropriately. The ED stated that although the resident was moved from the dining room to her room, he was informed that an unresponsive person can go up to five minutes without CPR before damages can occur. The ED stated that he paced it himself, and where the incident happed to Resident #1's room location was only ,[DATE] steps. He stated that he did not account for how long it took staff to transfer resident to her bed and to get back board under her. ED stated that the process his staff took he considered it an immediate response. Review of Resident Council Minutes, dated [DATE], reported vegetables sometimes too hard to chew. There was no subsequent Resident Council Minutes. There was no documentation that issue was addressed by the facility. Review of Emergency Procedure for Choking, dated [DATE], reflected the following: .4. Call for help, but stay with the resident. .5. Quickly assure the resident that you are going to stay and assist him or her. .6. If the resident cannot cough, only then should abdominal thrusts be performed . .h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Review of A step-by-step guide explaining what to do in a choking emergency, obtained on [DATE] from https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637, reflected the following: To clear the airway of an unconscious person: Lower the person on his or her back onto the floor, arms to the side. Clear the airway. If a blockage is visible at the back of the throat or high in the throat, reach a finger into the mouth and sweep out the cause of the blockage. Don't try a finger sweep if you can't see the object. Be careful not to push the food or object deeper into the airway, which can happen easily in young children. Begin CPR if the object remains lodged and the person doesn't respond after you take the above measures. The chest compressions used in CPR may dislodge the object. Remember to recheck the mouth periodically. Review of Policy Emergency Procedure-Cardiopulmonary Resuscitation, dated [DATE], reported the following: .5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. .6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. .8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advances Life Support (ALS). .9. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: .a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exits for that individual; or .b. There are obvious signs of irreversible death. An Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:17 PM. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 2:58 PM. The Plan of Removal reflected: In their discussion with the facility, HHSC stated alleged that the facility created an Immediate Jeopardy condition by: 1. The facility discontinued the [MEDICATION NAME] Maneuver after 2 unsuccessful attempts to dislodge food that the resident was choking on. Company Policy and Procedure dictates that the maneuver continue until either the foreign object is dislodged, or until the person becomes unconscious. 2. Initial CPR was begun by a Dietary Aide who is not certified on CPR despite multiple nurses and nurse aides being present in the room. The facility identified the following residents as being at risk of aspiration; Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8. All resident records have been audited to identify any other residents at risk for aspiration. None were found. This audit was completed immediately [DATE] by facility ADON. These residents were identified from the eMar based on a [DIAGNOSES REDACTED]. .The first step the facility will take to remove the immediacy, will be to inservice all clinical and dietary staff currently at the facility, including the DON, on the P&P (policy and procedure) regarding continuing the [MEDICATION NAME] Maneuver until the resident has passed out or until the foreign object is removed. This inservice is currently being done by (RN I), and (Senior Nurse Consultant) for (the facility). Any PRN staff or any staff currently on leave will be inserviced prior to returning to work. Competency drills will be done on medical emergency response drills, (cardiac and respiratory), weekly times 4 and monthly times 3. Drills will be monitored by the regional nurse. The drills will be evaluated for staff performance with appropriate counseling and retaining as needed. Inservices on Abuse and Neglect will be conducted by Executive Director or designee. Source documentation will be Abuse/Neglect Policies and Procedures. This training will include all facility staff. The facility will validate CPR and [MEDICATION NAME] competency via return demonstration with all licensed staff, whether currently certified or not. This will begin taking place on-site on [DATE] by certified BLS trainers from outside (the facility). Anticipated completion [DATE]. Clinical staff will not be allowed to provide care for any of the above identified at-risk residents until they have attended the inservice. CPR will only be done by staff who are certified. For purposes of this plan, only licensed clinical staff will participate in the competency testing. The seven residents identified as being at risk will be observed during meal service by licensed nurses, for signs of aspiration. The food service supervisor will monitoring food service to make sure that those seven residents' modified diets are served as ordered by physician. The food service manager will submit weekly reports of observations. No licensed staff will be allowed to work until their CPR certification is verified. Dietary staff have been instructed not to do CPR. The facility will immediately add a note to each med cart of the residents at risk for aspiration. This was done on [DATE]. An alert will be added to the eMar for every resident on the list for at risk for aspiration precautions. This was done [DATE]. Monitoring interviews were conducted at various times on [DATE] with staff the following staff: CNA E, CNA F, CAN G, CNA H, CNA J, CNA B, CNA K, LVN L, LVN M, RN D, RN N, DON, ADON, RN M. Staff interviewed were representative of various facility shifts. Staff was able to provide return demonstration and competency regarding training over the [MEDICATION NAME] Maneuver and CPR and competency regarding abuse and neglect. CMS Form 672 signed and dated by the DON on [DATE] revealed resident census of 63.

Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation result in serious bodily injury to the state agency in accordance with State Law for one (Resident #1) of six residents reviewed neglect. 1. The facility failed to report to the State Agency Resdient #1 had a choking incident on [DATE] which resulted in the resident's death. Facility did not report the incident to State Agency until three days later on [DATE]. The DON failed to maintain delivery of the [MEDICATION NAME] maneuver to Resident #1, who began choking in the dining room on [DATE], until the object was dislodged and or the resident lost consciousness and required a different intervention. DON, RN C, RN D and the ADON, who were CPR certified individuals, failed to correctly initiate Cardiopulmonary Resuscitation (CPR) for Resident #1 when she was identified as being unresponsive. Resident was transferred from the dining room to resident room while choking and then transferred to the bed with a backer board where her feet were hanging off the bed. Chest Compressions were not conducted correctly to be effective. DON placed a non-rebreather mask (a device used to deliver oxygen that requires the resident can breathe unassisted) on Resident #1 who was not breathing on their own at the time. By using the wrong type of oxygen delivery mask, the oxygen was not being delivered to the resident effectively. As a result of the facility's failures, the resident expired from the choking event on [DATE] with a cause of death, Asphyxia due to choking on food. The facility failed to report the incident to the state agency until three days after resident's death on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. Although, the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern due to needing to train staff and monitor their implementation of the Plan of Removal (POR). These failures could affect all 63 residents by placing them at risk of incidents going unreported and uninvesigated. Findings Included: Review of Resident #1's undated face sheet reflected the resident was a [AGE] year old female who admitted to the facility on [DATE] and expired on [DATE]. The resident had [DIAGNOSES REDACTED]. The Face Sheet reported that Resident #1 was a full code. Resident #1's MDS assessment, dated [DATE], reported Resident #1 had clear speech and she was able to make herself understood and she understood others. The resident was cognitively impaired. She required extensive assistance from staff with bed mobility, transfers, and locomotion on unit, dressing, and toilet use. She required limited assistance from staff with eating and personal hygiene. Resident #1 used a wheelchair for mobility. The MDS reported that Resident #1 only required setup or clean-up assistance with eating. The MDS reported that Resident #1 exhibited swallowing disorder symptoms of coughing or choking during meals or when swallowing medications. Resident #1 had a mechanically altered diet. The MDS reported that resident received speech therapy, occupational therapy, and physical therapy. Review of Resident #1's SLP Evaluation and Plan of Treatment, dated [DATE], reported that it was recommended that the resident receive Mechanical Soft Textured diet and thin liquids, and that she receive close supervision for oral intake. The evaluation revealed mild oral, likely pharyngeal weakness affecting her ability to safely swallow. It reported that the resident was at risk for aspiration and skilled SLP services for dysphagia were warranted to assess/evaluate the least restrictive oral intake, minimize aspiration/risk of and instruct family/staff in compensation techniques in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs and safely consume highest level of oral intake. Review of Resident #1's Speech Therapy Treatment Encounter Notes, dated [DATE] reflected: Patient (Resident 1) saw at beginning of lunchtime meal. Patient on mechanical soft solids and thin liquids via cup rim. Patient drank thin liquid via cup rim during meal with x1 immediate cough. Patient with disorganized and delayed mastication, along with L (left) side pocketing and residue. A Speech Therapy Note dated [DATE] reflected: Medications were administered whole with difficulty swallowing. Pt (Resident #1) ended up chewing medication, pills given in applesauce with improved swallow function, however, continued to chew larger meds. Nursing advised to crush meds in puree. Review of Resident #1's Progress Notes, dated [DATE] and written by the DON, reported The resident was seen eating lunch, up on her wheelchair. She ate 75% of lunch served. As the resident was wheeling herself away from the table, she stopped I noticed her stoic with eyes wide open. At that time, I ran to her, while the CNA closer to her immediately started the [MEDICATION NAME] maneuver. Asked if she was ok, no response noted. I swept her mouth for visible food particle, but the resident tried to bite. She (resident) was wheeled to her room by the staff, and 911 was called. No pulse felt, resident was unresponsive, CPR started. Suctioning initiated. CPR continued till paramedics arrived, at about 13:06 (1:06pm) and they took over. Review of Resident #1's Progress Notes, dated [DATE] at 16:31(4:31pm) by LVN A revealed residents' family member arrived at the facility and notified staff that resident had expired. Review of local county medical examiner report revealed Resident #1 time of death was [DATE] at 1:32PM. Cause of death is listed as Asphyxia Due to: Choking (FOOD). Review of local fire department Patient Care Record dated [DATE] revealed dispatch notified at 12:53PM of resident choking. EMS arrived at 1:01PM. Narrative: Medic was dispatched to a choking persons a call and arrived to find [AGE] year old female in [MEDICAL CONDITION] with CPR in progress. Upon arrival the patient was found lying in her nursing home facility bed unconscious and unresponsive, with her legs hanging off the end of the bed. The facilities staff was performing poor quality CPR and found holding a non-rebreather over the patients mouth flowing at 151pm. Manual chest compressions were initiated by paramedic at the time of making patient contact .The patients airway was inspected using a mac 3 blade by paramedic and a pellet of chewed carrots approximately 6cm in length and 2cm in diameter was removed from the patients airway using Magill forceps. An intubation attempt was performed as indicated above. Upon initiating respirations food had immediately begun to come up the intubation tube, suction was the initiated to attempt to remove the foreign objects. Phone interview with Paramedic on [DATE] at 1:27PM stated he was one of several responders to the [DATE] call involving Resident #1. He stated he entered Resident #1's room, and saw resident lying in bed with a backer board under her and her feet hanging off the bed. He stated there was one worker doing some CPR and another worker holding an incorrect bag over resident's mouth intended for oxygen. Paramedic stated he considered the CPR that had been delivered to Resident #1 as poor because the staff's form was not correct. He stated the staff appeared afraid to hurt resident and that she was not doing deep chest compressions. Paramedic stated that his Lieutenant removed what appeared to be a pretty solid chewed up carrots about the size of a thumb out of resident's airway. He stated the carrots were pressed baby carrots and were solid in form to where they were solid enough to stick to the forceps like a fork and remain solid through removal. He stated if the carrots were chewed up enough or a mechanical soft texture it would have been able to be mashed up upon removal but stated the carrots were solid. Paramedic stated he was not aware that Resident #1 was moved from the dining room to her room and that in his judgement resident should have not been moved and emergency services should have been done on site. Review of hospital provider notes dated [DATE] revealed HPI: Pt (Resident) was eating lunch when she choked and collapsed. CPR was started on scene. EMR arrived at 1308 (1:08pm) and pt was asystole (cardiac standstill or absence of heartbeat). CPR started by EMS. Pt (Resident) received aminophylline, [MEDICATION NAME] x2, and EPI. Pt was intubated en route. Review of Resident #1 Progress Note dated [DATE] reported resident's daughter in facility to pick up resident belonging, states resident has expired. In an interview with the ADON on [DATE] at 3:29 PM, she stated that Resident #1's family came to the facility after 2:00 PM, but before 5:00 PM. The ADON stated it was 2 women and a man; one of the two women was identified as the resident's daughter. The ADON stated the daughter asked her and RN D what Resident #1 had choked on. The ADON stated that they were unsure and did not know what the resident had eaten, so they went and asked Resident #1's table mate who told them she had only eaten two bites of carrots during that meal. Review of Provider Investigation Report dated [DATE] signed by the Administrator revealed the incident occurred on [DATE] at approximately 1:00PM when Resident #1 was found to be choking in the dining room where the [MEDICATION NAME] Maneuver was performed and resident became unresponsive. The facility did not report the incident to the state agency until three days after the incident occurred when the medical examiner confirmed cause of death to be asphyxia due to choking (FOOD). The report revealed the incident was not reported on the original date of death due to choking because clinical management at the time of transport to the ER, that Resident #1 had experienced a medical change in condition rather than choking. Review of the Menu for Friday, [DATE] reflected Baked fish Florentine, Seasoned red potatoes, parslied baby carrots, bread or roll and butter or margarine. The alternate meal was Swedish meatballs with gravy, red potatoes, parslied baby carrots, bread or roll and butter or margarine and banana cream pie with choice of beverage. Interview with CNA E on [DATE] at 1:25 PM revealed that she worked and responded to the choking incident for Resident #1 on [DATE]. CNA E stated that Resident #1 was eating (what she was eating was unknown) and right in the middle of her eating, CNA E noticed that Resident #1 started self-propelling herself in her wheelchair away from the table. CNA E approached the resident and asked if she needed anything but the resident did not respond and started waiving her hands towards her neck. CNA E stated that she asked the resident if she was choking and the resident nodded yes. CNA E stated that she then got the resident out of her wheelchair with the help of the resident and she started the [MEDICATION NAME] maneuver and yelled for help. CNA E stated that the DON responded to her call of help and the DON took over the [MEDICATION NAME]. CNA E stated that the DON was doing the [MEDICATION NAME] maneuver and she noticed that the DON put the resident back into her wheelchair. CNA E stated that the resident was fighting for air whenever the DON wheeled the resident into her room from out of the dining room. CNA E stated that she knew Resident #1 was fighting for air because she was still waving her hands towards her neck. In an interview with RN C on [DATE] at 2:10 PM, RN C stated that she was at the nurses' station charting when she heard and saw staff running towards Resident #1. She stated that she saw CNA E doing the [MEDICATION NAME] maneuver and the DON swept Resident #1's mouth, but food was not found. RN C stated that she heard the DON state she was bitten, and at that time Resident #1 was sat back into her wheelchair by the DON and wheeled to Resident #1's room. RN C stated that she knew Resident #1 was choking because her eyes were bulging and she was shaking her head yes. RN C stated that she noticed Resident #1 was not responsive whenever the resident was transferred from her wheelchair to the bed, and that the DON stated that the resident did not have a pulse and or breathing. RN C stated that CPR was started by the DON and Dietary Aide because the Dietary Aide was closest to the resident to start chest compressions. Dietary Aide provided the first round of chest compressions, and the next rounds were by RN C, then RN D and then the ADON until EMS arrived. RN C stated that best practice was to start CPR on the spot and not to move the resident because the quicker CPR is started, the better the survival rate. Interview with CNA B on [DATE] at 2:27 PM stated that she was in the dining room feeding a resident whenever she heard CNA E yelling Resident #1 was choking. CNA B stated that the DON took over the [MEDICATION NAME] and the DON put her hand in the resident's mouth where she was bitten. At that point, the resident was sat down in her wheelchair where she sat gasping for air, still choking. CNA B stated the resident was pushed to her room. In an interview with the ADON on [DATE] at 3:29 PM, she stated that she was on the B-side of the dining room whenever she heard staff yelling, She's choking!, and she then ran over and saw the DON sweeping Resident #1's mouth. She then noticed that Resident #1 was biting down and she heard a nurse say, Let's take the resident to her room, from the middle of the dining room. The ADON stated that the resident was still choking whenever she was put back into her wheelchair because her eyes were open and she was gasping for air. The ADON stated that the [MEDICATION NAME] should not have been stopped until the item came up and or the resident lost consciousness. ADON stated Resident #1 was transferred to her bed by herself, Dietary Aide, RN D, CNA B, and RN C and that at that time, resident was not responsive. The ADON stated that the DON checked for a pulse and breathing, and that there was none. The ADON stated that someone had gotten the crash cart that had emergency supplies on it, and one of those supplies was a back board that was needed so it could be placed under the resident to start CPR. The ADON stated that CPR was initiated by the DON and a Dietary Aide, and chest compressions were then completed by RN C, herself, and then another employee, whom she was unable to recall, until EMS arrived. In an interview with the DON on [DATE] at 2:49 PM, she stated that she was in the dining room feeding and eating with a resident whenever she heard CNA E yelling for help. She then ran over to Resident #1 and started a mouth sweep where she could not get in her mouth because the resident was biting down. The DON stated that she then started the [MEDICATION NAME] maneuver and tried to do another mouth sweep and the resident bit down on her finger. At that time resident was sat back down in her wheelchair. DON stated that Resident #1 was still choking whenever she was sat back down in her chair but was changing in color. The DON stated that she stopped the [MEDICATION NAME] because it was painful and hurt really bad whenever the resident bit her, and that she thought another staff had started the [MEDICATION NAME], but did not know because she left to the nurse's station to call [DATE]. DON stated the call to Emergency Services lasted a little over one minute, but no more than two minutes. She then went to Resident #1's room where the resident had been transferred to her bed. The DON stated that whenever she went to the room, she saw Dietary Aide doing chest compressions. The DON stated that she went checked Resident #1 for a pulse and for breathing, and she stated that resident did not have either. The DON stated that she got a breather bag and placed it over resident's mouth to provide oxygen while the Dietary Aide did chest compressions. The DON stated that she only provided oxygen to the resident while staff (DON was unable to recall all the staff who helped and in what order) did chest compressions. The DON stated that the resident was moved to her room for safety, and she knew they would need to do suctioning and there were no wall outlets where the resident started choking at. A joint interview on [DATE] at 1:23 PM with SLPI F and SLPI G reported that Resident #1 required close supervision with meals. SLPI F defined close supervision as one-on-one supervision while the resident ate all meals. Staff reported that anytime a resident was at risk for aspiration, it was identified on the physician orders [REDACTED]. The identified intervention was close supervision, safe swallowing techniques and checking for pocketing. SLPI G looked at Resident #1's electronic chart and stated that there were no orders for aspiration precautions in her chart, and there should have been one. In an interview with Dietary Aide A on [DATE] at 9:05 AM, she stated that she was serving in the kitchen near the nurse's station whenever she saw Resident #1 eating carrots. Dietary Aide stated that Resident #1 was served a mechanical soft diet of carrots and meatballs with gravy. Dietary Aide stated that after the incident, she observed the plate and noticed that the resident only ate a few carrots. Dietary Aide stated that she heard staff yelling and saw some running towards Resident #1. She stated that she saw the DON helping the resident by doing the [MEDICATION NAME] maneuver, and the DON put her finger into the resident's mouth, and the resident bit down on the DON's finger. The resident was then placed back into her wheelchair. Dietary Aide stated that Resident #1's, eyes were rolling back and that she acted like she could not breathe, and then everyone rolled resident in her wheelchair back to her room. Dietary Aide stated that she helped other staff put the resident in her bed, and while they were putting her in the bed she was still acting as if she could not breathe. Dietary Aide stated that the DON went to get oxygen for the resident and other items that she was unsure what they were called. Dietary Aide stated that she had gotten two paper towels to put over the resident's mouth to create a barrier. She stated that the resident had saliva coming out of her mouth, and that she just wanted to help the resident because she knew the resident was not responsive. So she tilted the resident's head back and pinched her nose and gave resident ,[DATE] breaths, provided chest pumps, and then the DON came back into the room. Dietary Aide stated that she wiped resident's mouth and she heard the DON say the resident was not responsive, so the DON put a mask over the resident's mouth and then Dietary Aide gave a round of chest compressions. Someone else then started giving chest pumps while the DON gave the resident oxygen. Dietary Aide stated that there were nurses in the room, but she just wanted to save the resident's life because everyone was helping with something. She said she was not trained and or certified to provide CPR, and that she was trying to help resident. Dietary Aide stated that she was unsure how long it took for CPR to get started or who was in the room at that time. In an interview with RN D on [DATE] at 1:46 PM, she stated that that she was on the phone whenever she heard someone yelling for help. RN D stated that she went with other staff to Resident #1's room to see what she could help with, and that she helped staff transfer the resident from her wheelchair to her bed. At that point, Resident #1 was unresponsive, and that she knew she was because once the resident was on the bed, RN D called the resident by name she touched, and shook resident, but there was no response from her. RN D stated that followed by that, the DON entered into the room and checked the resident's pulse and to see if she was breathing, and there was nothing noted. RN D stated that CPR was started by Dietary Aide and the DON. She stated the DON provided oxygen to the resident while tilting the resident's head back, and the Dietary Aide did chest compressions. RN D stated that Dietary Aide did CPR first because she was closest to resident. RN D stated that CPR was started within two minutes of the resident becoming unresponsive. RN D stated that CPR should have been done on site in the dining room and the resident should have not been moved to her room. In an interview with the ED on [DATE] at 6:24 PM, he stated that his clinical department responded to Resident #1 appropriately. The ED stated that although the resident was moved from the dining room to her room, he was informed that an unresponsive person can go up to five minutes without CPR before damages can occur. The ED stated that he paced it himself, and where the incident happed to Resident #1's room location was only ,[DATE] steps. He stated that he did not account for how long it took staff to transfer resident to her bed and to get back board under her. ED stated that the process his staff took he considered it an immediate response. Review of Resident Council Minutes, dated [DATE], reported vegetables sometimes too hard to chew. There was no subsequent Resident Council Minutes. There was no documentation that issue was addressed by the facility. Review of Emergency Procedure for Choking, dated [DATE], reflected the following: .4. Call for help, but stay with the resident. .5. Quickly assure the resident that you are going to stay and assist him or her. .6. If the resident cannot cough, only then should abdominal thrusts be performed . .h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Review of A step-by-step guide explaining what to do in a choking emergency, obtained on [DATE] from https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637, reflected the following: To clear the airway of an unconscious person: Lower the person on his or her back onto the floor, arms to the side. Clear the airway. If a blockage is visible at the back of the throat or high in the throat, reach a finger into the mouth and sweep out the cause of the blockage. Don't try a finger sweep if you can't see the object. Be careful not to push the food or object deeper into the airway, which can happen easily in young children. Begin CPR if the object remains lodged and the person doesn't respond after you take the above measures. The chest compressions used in CPR may dislodge the object. Remember to recheck the mouth periodically. Review of Policy Emergency Procedure-Cardiopulmonary Resuscitation, dated [DATE], reported the following: .5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. .6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. .8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advances Life Support (ALS). .9. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: .a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exits for that individual; or .b. There are obvious signs of irreversible death. Review of Abuse and Neglect - Assessment and Recognition dated [DATE] revealed Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Any suspected or substantiated incidents of . neglect of the residents is immediately reported to the Administration and appropriate state government and city agencies. Review of Abuse and Neglect Clinical Protocol dated [DATE] revealed The staff and practitioners will investigate possible occurrences of abuse and neglect to clarify what happened and identify causes. The facility management and staff will comply with applicable laws and regulations pertaining to the documentation and management of abuse and neglect. An Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:17 PM. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 2:58 PM. The Plan of Removal reflected: In their discussion with the facility, HHSC stated alleged that the facility created an Immediate Jeopardy condition by: 1. The facility discontinued the [MEDICATION NAME] Maneuver after 2 unsuccessful attempts to dislodge food that the resident was choking on. Company Policy and Procedure dictates that the maneuver continue until either the foreign object is dislodged, or until the person becomes unconscious. 2. Initial CPR was begun by a Dietary Aide who is not certified on CPR despite multiple nurses and nurse aides being present in the room. The facility identified the following residents as being at risk of aspiration; Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8. All resident records have been audited to identify any other residents at risk for aspiration. None were found. This audit was completed immediately [DATE] by facility ADON. These residents were identified from the eMar based on a [DIAGNOSES REDACTED]. .The first step the facility will take to remove the immediacy, will be to inservice all clinical and dietary staff currently at the facility, including the DON, on the P&P (policy and procedure) regarding continuing the [MEDICATION NAME] Maneuver until the resident has passed out or until the foreign object is removed. This inservice is currently being done by (RN I), and (Senior Nurse Consultant) for (the facility). Any PRN staff or any staff currently on leave will be inserviced prior to returning to work. Competency drills will be done on medical emergency response drills, (cardiac and respiratory), weekly times 4 and monthly times 3. Drills will be monitored by the regional nurse. The drills will be evaluated for staff performance with appropriate counseling and retaining as needed. Inservices on Abuse and Neglect will be conducted by Executive Director or designee. Source documentation will be Abuse/Neglect Policies and Procedures. This training will include all facility staff. The facility will validate CPR and [MEDICATION NAME] competency via return demonstration with all licensed staff, whether currently certified or not. This will begin taking place on-site on [DATE] by certified BLS trainers from outside (the facility). Anticipated completion [DATE]. Clinical staff will not be allowed to provide care for any of the above identified at-risk residents until they have attended the inservice. CPR will only be done by staff who are certified. For purposes of this plan, only licensed clinical staff will participate in the competency testing. The seven residents identified as being at risk will be observed during meal service by licensed nurses, for signs of aspiration. The food service supervisor will monitoring food service to make sure that those seven residents' modified diets are served as ordered by physician. The food service manager will submit weekly reports of observations. No licensed staff will be allowed to work until their CPR certification is verified. Dietary staff have been instructed not to do CPR. The facility will immediately add a note to each med cart of the residents at risk for aspiration. This was done on [DATE]. An alert will be added to the eMar for every resident on the list for at risk for aspiration precautions. This was done [DATE]. Monitoring interviews were conducted at various times on [DATE] with staff the following staff: CNA E, CNA F, CAN G, CNA H, CNA J, CNA B, CNA K, LVN L, LVN M, RN D, RN N, DON, ADON, RN M. Staff interviewed were representative of various facility shifts. Staff was able to provide return demonstration and competency regarding training over the [MEDICATION NAME] Maneuver and CPR and competency regarding abuse and neglect. CMS Form 672 signed and dated by the DON on [DATE] revealed resident census of 63.

Based on interview and record review, the facility failed to thouroughly inveisgate alleged violations involving neglect one (Resident #1) of six residents reviewed neglect. 1. The Adinistrator failed to thougoughy invesitage a choking incident that occured on [DATE] which resulted in Resident #1's death. The DON failed to maintain delivery of the [MEDICATION NAME] maneuver to Resident #1, who began choking in the dining room on [DATE], until the object was dislodged and or the resident lost consciousness and required a different intervention. DON, RN C, RN D and the ADON, who were CPR certified individuals, failed to correctly initiate Cardiopulmonary Resuscitation (CPR) for Resident #1 when she was identified as being unresponsive. Resident was transferred from the dining room to resident room while choking and then transferred to the bed with a backer board where her feet were hanging off the bed. Chest Compressions were not conducted correctly to be effective. DON placed a non-rebreather mask (a device used to deliver oxygen that requires the resident can breathe unassisted) on Resident #1 who was not breathing on their own at the time. By using the wrong type of oxygen delivery mask, the oxygen was not being delivered to the resident effectively. As a result of the facility's failures, the resident expired from the choking event on [DATE] with a cause of death, Asphyxia due to choking on food. The facility failed to report the incident to the state agency until three days after resident's death on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. Although, the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern due to needing to train staff and monitor their implementation of the Plan of Removal (POR). These failures could affect all 63 residents by placing them at risk of incidents of neglect not being thouroughly inveisgated by the facility. Findings Included: Review of Resident #1's undated face sheet reflected the resident was a [AGE] year old female who admitted to the facility on [DATE] and expired on [DATE]. The resident had [DIAGNOSES REDACTED]. The Face Sheet reported that Resident #1 was a full code. Resident #1's MDS assessment, dated [DATE], reported Resident #1 had clear speech and she was able to make herself understood and she understood others. The resident was cognitively impaired. She required extensive assistance from staff with bed mobility, transfers, and locomotion on unit, dressing, and toilet use. She required limited assistance from staff with eating and personal hygiene. Resident #1 used a wheelchair for mobility. The MDS reported that Resident #1 only required setup or clean-up assistance with eating. The MDS reported that Resident #1 exhibited swallowing disorder symptoms of coughing or choking during meals or when swallowing medications. Resident #1 had a mechanically altered diet. The MDS reported that resident received speech therapy, occupational therapy, and physical therapy. Review of Resident #1's SLP Evaluation and Plan of Treatment, dated [DATE], reported that it was recommended that the resident receive Mechanical Soft Textured diet and thin liquids, and that she receive close supervision for oral intake. The evaluation revealed mild oral, likely pharyngeal weakness affecting her ability to safely swallow. It reported that the resident was at risk for aspiration and skilled SLP services for dysphagia were warranted to assess/evaluate the least restrictive oral intake, minimize aspiration/risk of and instruct family/staff in compensation techniques in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs and safely consume highest level of oral intake. Review of Resident #1's Speech Therapy Treatment Encounter Notes, dated [DATE] reflected: Patient (Resident 1) saw at beginning of lunchtime meal. Patient on mechanical soft solids and thin liquids via cup rim. Patient drank thin liquid via cup rim during meal with x1 immediate cough. Patient with disorganized and delayed mastication, along with L (left) side pocketing and residue. A Speech Therapy Note dated [DATE] reflected: Medications were administered whole with difficulty swallowing. Pt (Resident #1) ended up chewing medication, pills given in applesauce with improved swallow function, however, continued to chew larger meds. Nursing advised to crush meds in puree. Review of Resident #1's Progress Notes, dated [DATE] and written by the DON, reported The resident was seen eating lunch, up on her wheelchair. She ate 75% of lunch served. As the resident was wheeling herself away from the table, she stopped I noticed her stoic with eyes wide open. At that time, I ran to her, while the CNA closer to her immediately started the [MEDICATION NAME] maneuver. Asked if she was ok, no response noted. I swept her mouth for visible food particle, but the resident tried to bite. She (resident) was wheeled to her room by the staff, and 911 was called. No pulse felt, resident was unresponsive, CPR started. Suctioning initiated. CPR continued till paramedics arrived, at about 13:06 (1:06pm) and they took over. Review of Resident #1's Progress Notes, dated [DATE] at 16:31(4:31pm) by LVN A revealed residents' family member arrived at the facility and notified staff that resident had expired. Review of local county medical examiner report revealed Resident #1 time of death was [DATE] at 1:32PM. Cause of death is listed as Asphyxia Due to: Choking (FOOD). Review of local fire department Patient Care Record dated [DATE] revealed dispatch notified at 12:53PM of resident choking. EMS arrived at 1:01PM. Narrative: Medic was dispatched to a choking persons a call and arrived to find [AGE] year old female in [MEDICAL CONDITION] with CPR in progress. Upon arrival the patient was found lying in her nursing home facility bed unconscious and unresponsive, with her legs hanging off the end of the bed. The facilities staff was performing poor quality CPR and found holding a non-rebreather over the patients mouth flowing at 151pm. Manual chest compressions were initiated by paramedic at the time of making patient contact .The patients airway was inspected using a mac 3 blade by paramedic and a pellet of chewed carrots approximately 6cm in length and 2cm in diameter was removed from the patients airway using Magill forceps. An intubation attempt was performed as indicated above. Upon initiating respirations food had immediately begun to come up the intubation tube, suction was the initiated to attempt to remove the foreign objects. Phone interview with Paramedic on [DATE] at 1:27PM stated he was one of several responders to the [DATE] call involving Resident #1. He stated he entered Resident #1's room, and saw resident lying in bed with a backer board under her and her feet hanging off the bed. He stated there was one worker doing some CPR and another worker holding an incorrect bag over resident's mouth intended for oxygen. Paramedic stated he considered the CPR that had been delivered to Resident #1 as poor because the staff's form was not correct. He stated the staff appeared afraid to hurt resident and that she was not doing deep chest compressions. Paramedic stated that his Lieutenant removed what appeared to be a pretty solid chewed up carrots about the size of a thumb out of resident's airway. He stated the carrots were pressed baby carrots and were solid in form to where they were solid enough to stick to the forceps like a fork and remain solid through removal. He stated if the carrots were chewed up enough or a mechanical soft texture it would have been able to be mashed up upon removal but stated the carrots were solid. Paramedic stated he was not aware that Resident #1 was moved from the dining room to her room and that in his judgement resident should have not been moved and emergency services should have been done on site. Review of hospital provider notes dated [DATE] revealed HPI: Pt (Resident) was eating lunch when she choked and collapsed. CPR was started on scene. EMR arrived at 1308 (1:08pm) and pt was asystole (cardiac standstill or absence of heartbeat). CPR started by EMS. Pt (Resident) received aminophylline, [MEDICATION NAME] x2, and EPI. Pt was intubated en route. Review of Resident #1 Progress Note dated [DATE] reported resident's daughter in facility to pick up resident belonging, states resident has expired. In an interview with the ADON on [DATE] at 3:29 PM, she stated that Resident #1's family came to the facility after 2:00 PM, but before 5:00 PM. The ADON stated it was 2 women and a man; one of the two women was identified as the resident's daughter. The ADON stated the daughter asked her and RN D what Resident #1 had choked on. The ADON stated that they were unsure and did not know what the resident had eaten, so they went and asked Resident #1's table mate who told them she had only eaten two bites of carrots during that meal. Review of Provider Investigation Report dated [DATE] signed by the Administrator revealed the incident occurred on [DATE] at approximately 1:00PM when Resident #1 was found to be choking in the dining room where the [MEDICATION NAME] Maneuver was performed and resident became unresponsive. The facility did not report the incident to the state agency until three days after the incident occurred when the medical examiner confirmed cause of death to be asphyxia due to choking (FOOD). The report revealed the incident was not reported on the original date of death due to choking because clinical management at the time of transport to the ER, that Resident #1 had experienced a medical change in condition rather than choking. Review of the Menu for Friday, [DATE] reflected Baked fish Florentine, Seasoned red potatoes, parslied baby carrots, bread or roll and butter or margarine. The alternate meal was Swedish meatballs with gravy, red potatoes, parslied baby carrots, bread or roll and butter or margarine and banana cream pie with choice of beverage. Interview with CNA E on [DATE] at 1:25 PM revealed that she worked and responded to the choking incident for Resident #1 on [DATE]. CNA E stated that Resident #1 was eating (what she was eating was unknown) and right in the middle of her eating, CNA E noticed that Resident #1 started self-propelling herself in her wheelchair away from the table. CNA E approached the resident and asked if she needed anything but the resident did not respond and started waiving her hands towards her neck. CNA E stated that she asked the resident if she was choking and the resident nodded yes. CNA E stated that she then got the resident out of her wheelchair with the help of the resident and she started the [MEDICATION NAME] maneuver and yelled for help. CNA E stated that the DON responded to her call of help and the DON took over the [MEDICATION NAME]. CNA E stated that the DON was doing the [MEDICATION NAME] maneuver and she noticed that the DON put the resident back into her wheelchair. CNA E stated that the resident was fighting for air whenever the DON wheeled the resident into her room from out of the dining room. CNA E stated that she knew Resident #1 was fighting for air because she was still waving her hands towards her neck. In an interview with RN C on [DATE] at 2:10 PM, RN C stated that she was at the nurses' station charting when she heard and saw staff running towards Resident #1. She stated that she saw CNA E doing the [MEDICATION NAME] maneuver and the DON swept Resident #1's mouth, but food was not found. RN C stated that she heard the DON state she was bitten, and at that time Resident #1 was sat back into her wheelchair by the DON and wheeled to Resident #1's room. RN C stated that she knew Resident #1 was choking because her eyes were bulging and she was shaking her head yes. RN C stated that she noticed Resident #1 was not responsive whenever the resident was transferred from her wheelchair to the bed, and that the DON stated that the resident did not have a pulse and or breathing. RN C stated that CPR was started by the DON and Dietary Aide because the Dietary Aide was closest to the resident to start chest compressions. Dietary Aide provided the first round of chest compressions, and the next rounds were by RN C, then RN D and then the ADON until EMS arrived. RN C stated that best practice was to start CPR on the spot and not to move the resident because the quicker CPR is started, the better the survival rate. Interview with CNA B on [DATE] at 2:27 PM stated that she was in the dining room feeding a resident whenever she heard CNA E yelling Resident #1 was choking. CNA B stated that the DON took over the [MEDICATION NAME] and the DON put her hand in the resident's mouth where she was bitten. At that point, the resident was sat down in her wheelchair where she sat gasping for air, still choking. CNA B stated the resident was pushed to her room. In an interview with the ADON on [DATE] at 3:29 PM, she stated that she was on the B-side of the dining room whenever she heard staff yelling, She's choking!, and she then ran over and saw the DON sweeping Resident #1's mouth. She then noticed that Resident #1 was biting down and she heard a nurse say, Let's take the resident to her room, from the middle of the dining room. The ADON stated that the resident was still choking whenever she was put back into her wheelchair because her eyes were open and she was gasping for air. The ADON stated that the [MEDICATION NAME] should not have been stopped until the item came up and or the resident lost consciousness. ADON stated Resident #1 was transferred to her bed by herself, Dietary Aide, RN D, CNA B, and RN C and that at that time, resident was not responsive. The ADON stated that the DON checked for a pulse and breathing, and that there was none. The ADON stated that someone had gotten the crash cart that had emergency supplies on it, and one of those supplies was a back board that was needed so it could be placed under the resident to start CPR. The ADON stated that CPR was initiated by the DON and a Dietary Aide, and chest compressions were then completed by RN C, herself, and then another employee, whom she was unable to recall, until EMS arrived. In an interview with the DON on [DATE] at 2:49 PM, she stated that she was in the dining room feeding and eating with a resident whenever she heard CNA E yelling for help. She then ran over to Resident #1 and started a mouth sweep where she could not get in her mouth because the resident was biting down. The DON stated that she then started the [MEDICATION NAME] maneuver and tried to do another mouth sweep and the resident bit down on her finger. At that time resident was sat back down in her wheelchair. DON stated that Resident #1 was still choking whenever she was sat back down in her chair but was changing in color. The DON stated that she stopped the [MEDICATION NAME] because it was painful and hurt really bad whenever the resident bit her, and that she thought another staff had started the [MEDICATION NAME], but did not know because she left to the nurse's station to call [DATE]. DON stated the call to Emergency Services lasted a little over one minute, but no more than two minutes. She then went to Resident #1's room where the resident had been transferred to her bed. The DON stated that whenever she went to the room, she saw Dietary Aide doing chest compressions. The DON stated that she went checked Resident #1 for a pulse and for breathing, and she stated that resident did not have either. The DON stated that she got a breather bag and placed it over resident's mouth to provide oxygen while the Dietary Aide did chest compressions. The DON stated that she only provided oxygen to the resident while staff (DON was unable to recall all the staff who helped and in what order) did chest compressions. The DON stated that the resident was moved to her room for safety, and she knew they would need to do suctioning and there were no wall outlets where the resident started choking at. A joint interview on [DATE] at 1:23 PM with SLPI F and SLPI G reported that Resident #1 required close supervision with meals. SLPI F defined close supervision as one-on-one supervision while the resident ate all meals. Staff reported that anytime a resident was at risk for aspiration, it was identified on the physician orders [REDACTED]. The identified intervention was close supervision, safe swallowing techniques and checking for pocketing. SLPI G looked at Resident #1's electronic chart and stated that there were no orders for aspiration precautions in her chart, and there should have been one. In an interview with Dietary Aide A on [DATE] at 9:05 AM, she stated that she was serving in the kitchen near the nurse's station whenever she saw Resident #1 eating carrots. Dietary Aide stated that Resident #1 was served a mechanical soft diet of carrots and meatballs with gravy. Dietary Aide stated that after the incident, she observed the plate and noticed that the resident only ate a few carrots. Dietary Aide stated that she heard staff yelling and saw some running towards Resident #1. She stated that she saw the DON helping the resident by doing the [MEDICATION NAME] maneuver, and the DON put her finger into the resident's mouth, and the resident bit down on the DON's finger. The resident was then placed back into her wheelchair. Dietary Aide stated that Resident #1's, eyes were rolling back and that she acted like she could not breathe, and then everyone rolled resident in her wheelchair back to her room. Dietary Aide stated that she helped other staff put the resident in her bed, and while they were putting her in the bed she was still acting as if she could not breathe. Dietary Aide stated that the DON went to get oxygen for the resident and other items that she was unsure what they were called. Dietary Aide stated that she had gotten two paper towels to put over the resident's mouth to create a barrier. She stated that the resident had saliva coming out of her mouth, and that she just wanted to help the resident because she knew the resident was not responsive. So she tilted the resident's head back and pinched her nose and gave resident ,[DATE] breaths, provided chest pumps, and then the DON came back into the room. Dietary Aide stated that she wiped resident's mouth and she heard the DON say the resident was not responsive, so the DON put a mask over the resident's mouth and then Dietary Aide gave a round of chest compressions. Someone else then started giving chest pumps while the DON gave the resident oxygen. Dietary Aide stated that there were nurses in the room, but she just wanted to save the resident's life because everyone was helping with something. She said she was not trained and or certified to provide CPR, and that she was trying to help resident. Dietary Aide stated that she was unsure how long it took for CPR to get started or who was in the room at that time. In an interview with RN D on [DATE] at 1:46 PM, she stated that that she was on the phone whenever she heard someone yelling for help. RN D stated that she went with other staff to Resident #1's room to see what she could help with, and that she helped staff transfer the resident from her wheelchair to her bed. At that point, Resident #1 was unresponsive, and that she knew she was because once the resident was on the bed, RN D called the resident by name she touched, and shook resident, but there was no response from her. RN D stated that followed by that, the DON entered into the room and checked the resident's pulse and to see if she was breathing, and there was nothing noted. RN D stated that CPR was started by Dietary Aide and the DON. She stated the DON provided oxygen to the resident while tilting the resident's head back, and the Dietary Aide did chest compressions. RN D stated that Dietary Aide did CPR first because she was closest to resident. RN D stated that CPR was started within two minutes of the resident becoming unresponsive. RN D stated that CPR should have been done on site in the dining room and the resident should have not been moved to her room. In an interview with the ED on [DATE] at 6:24 PM, he stated that his clinical department responded to Resident #1 appropriately. The ED stated that although the resident was moved from the dining room to her room, he was informed that an unresponsive person can go up to five minutes without CPR before damages can occur. The ED stated that he paced it himself, and where the incident happed to Resident #1's room location was only ,[DATE] steps. He stated that he did not account for how long it took staff to transfer resident to her bed and to get back board under her. ED stated that the process his staff took he considered it an immediate response. Review of Resident Council Minutes, dated [DATE], reported vegetables sometimes too hard to chew. There was no subsequent Resident Council Minutes. There was no documentation that issue was addressed by the facility. Review of Emergency Procedure for Choking, dated [DATE], reflected the following: .4. Call for help, but stay with the resident. .5. Quickly assure the resident that you are going to stay and assist him or her. .6. If the resident cannot cough, only then should abdominal thrusts be performed . .h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Review of A step-by-step guide explaining what to do in a choking emergency, obtained on [DATE] from https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637, reflected the following: To clear the airway of an unconscious person: Lower the person on his or her back onto the floor, arms to the side. Clear the airway. If a blockage is visible at the back of the throat or high in the throat, reach a finger into the mouth and sweep out the cause of the blockage. Don't try a finger sweep if you can't see the object. Be careful not to push the food or object deeper into the airway, which can happen easily in young children. Begin CPR if the object remains lodged and the person doesn't respond after you take the above measures. The chest compressions used in CPR may dislodge the object. Remember to recheck the mouth periodically. Review of Policy Emergency Procedure-Cardiopulmonary Resuscitation, dated [DATE], reported the following: .5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. .6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. .8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advances Life Support (ALS). .9. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: .a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exits for that individual; or .b. There are obvious signs of irreversible death. Review of Abuse and Neglect - Assessment and Recognition dated [DATE] revealed Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Any suspected or substantiated incidents of . neglect of the residents is immediately reported to the Administration and appropriate state government and city agencies. Review of Abuse and Neglect Clinical Protocol dated [DATE] revealed The staff and practitioners will investigate possible occurrences of abuse and neglect to clarify what happened and identify causes. The facility management and staff will comply with applicable laws and regulations pertaining to the documentation and management of abuse and neglect. An Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:17 PM. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 2:58 PM. The Plan of Removal reflected: In their discussion with the facility, HHSC stated alleged that the facility created an Immediate Jeopardy condition by: 1. The facility discontinued the [MEDICATION NAME] Maneuver after 2 unsuccessful attempts to dislodge food that the resident was choking on. Company Policy and Procedure dictates that the maneuver continue until either the foreign object is dislodged, or until the person becomes unconscious. 2. Initial CPR was begun by a Dietary Aide who is not certified on CPR despite multiple nurses and nurse aides being present in the room. The facility identified the following residents as being at risk of aspiration; Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8. All resident records have been audited to identify any other residents at risk for aspiration. None were found. This audit was completed immediately [DATE] by facility ADON. These residents were identified from the eMar based on a [DIAGNOSES REDACTED]. .The first step the facility will take to remove the immediacy, will be to inservice all clinical and dietary staff currently at the facility, including the DON, on the P&P (policy and procedure) regarding continuing the [MEDICATION NAME] Maneuver until the resident has passed out or until the foreign object is removed. This inservice is currently being done by (RN I), and (Senior Nurse Consultant) for (the facility). Any PRN staff or any staff currently on leave will be inserviced prior to returning to work. Competency drills will be done on medical emergency response drills, (cardiac and respiratory), weekly times 4 and monthly times 3. Drills will be monitored by the regional nurse. The drills will be evaluated for staff performance with appropriate counseling and retaining as needed. Inservices on Abuse and Neglect will be conducted by Executive Director or designee. Source documentation will be Abuse/Neglect Policies and Procedures. This training will include all facility staff. The facility will validate CPR and [MEDICATION NAME] competency via return demonstration with all licensed staff, whether currently certified or not. This will begin taking place on-site on [DATE] by certified BLS trainers from outside (the facility). Anticipated completion [DATE]. Clinical staff will not be allowed to provide care for any of the above identified at-risk residents until they have attended the inservice. CPR will only be done by staff who are certified. For purposes of this plan, only licensed clinical staff will participate in the competency testing. The seven residents identified as being at risk will be observed during meal service by licensed nurses, for signs of aspiration. The food service supervisor will monitoring food service to make sure that those seven residents' modified diets are served as ordered by physician. The food service manager will submit weekly reports of observations. No licensed staff will be allowed to work until their CPR certification is verified. Dietary staff have been instructed not to do CPR. The facility will immediately add a note to each med cart of the residents at risk for aspiration. This was done on [DATE]. An alert will be added to the eMar for every resident on the list for at risk for aspiration precautions. This was done [DATE]. Monitoring interviews were conducted at various times on [DATE] with staff the following staff: CNA E, CNA F, CAN G, CNA H, CNA J, CNA B, CNA K, LVN L, LVN M, RN D, RN N, DON, ADON, RN M. Staff interviewed were representative of various facility shifts. Staff was able to provide return demonstration and competency regarding training over the [MEDICATION NAME] Maneuver and CPR and competency regarding abuse and neglect. CMS Form 672 signed and dated by the DON on [DATE] revealed resident census of 63.

Based on interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one (Resident #1) of six residents reviewed quality of care. 1. The DON failed to maintain delivery of the [MEDICATION NAME] maneuver to Resident #1, who began choking in the dining room on [DATE], until the object was dislodged and or the resident lost consciousness and required a different intervention. 2. DON, RN C, RN D and the ADON, who were CPR certified individuals, failed to correctly initiate Cardiopulmonary Resuscitation (CPR) for Resident #1 when she was identified as being unresponsive. Resident was transferred from the dining room to resident room while choking and then transferred to the bed with a backer board where her feet were hanging off the bed. Chest Compressions were not conducted correctly to be effective. DON placed a non-rebreather mask (a device used to deliver oxygen that requires the resident can breathe unassisted) on Resident #1 who was not breathing on their own at the time. By using the wrong type of oxygen delivery mask, the oxygen was not being delivered to the resident effectively. As a result of the facility's failures, the resident expired from the choking event on [DATE] with a cause of death, Asphyxia due to choking on food. An Immediate Jeopardy (IJ) was identified on [DATE]. Although, the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern due to needing to train staff and monitor their implementation of the Plan of Removal (POR). These failures could affect all 63 residents who could need the [MEDICATION NAME] maneuver or CPR by placing them at risk for aspiration and death. Findings Included: Review of Resident #1's undated face sheet reflected the resident was a [AGE] year old female who admitted to the facility on [DATE] and expired on [DATE]. The resident had [DIAGNOSES REDACTED]. The Face Sheet reported that Resident #1 was a full code. Resident #1's MDS assessment, dated [DATE], reported Resident #1 had clear speech and she was able to make herself understood and she understood others. The resident was cognitively impaired. She required extensive assistance from staff with bed mobility, transfers, and locomotion on unit, dressing, and toilet use. She required limited assistance from staff with eating and personal hygiene. Resident #1 used a wheelchair for mobility. The MDS reported that Resident #1 only required setup or clean-up assistance with eating. The MDS reported that Resident #1 exhibited swallowing disorder symptoms of coughing or choking during meals or when swallowing medications. Resident #1 had a mechanically altered diet. The MDS reported that resident received speech therapy, occupational therapy, and physical therapy. Review of Resident #1's SLP Evaluation and Plan of Treatment, dated [DATE], reported that it was recommended that the resident receive Mechanical Soft Textured diet and thin liquids, and that she receive close supervision for oral intake. The evaluation revealed mild oral, likely pharyngeal weakness affecting her ability to safely swallow. It reported that the resident was at risk for aspiration and skilled SLP services for dysphagia were warranted to assess/evaluate the least restrictive oral intake, minimize aspiration/risk of and instruct family/staff in compensation techniques in order to enhance patient's quality of life by improving ability to meet primary nutrition/hydration needs and safely consume highest level of oral intake. Review of Resident #1's Speech Therapy Treatment Encounter Notes, dated [DATE] reflected: Patient (Resident 1) saw at beginning of lunchtime meal. Patient on mechanical soft solids and thin liquids via cup rim. Patient drank thin liquid via cup rim during meal with x1 immediate cough. Patient with disorganized and delayed mastication, along with L (left) side pocketing and residue. A Speech Therapy Note dated [DATE] reflected: Medications were administered whole with difficulty swallowing. Pt (Resident #1) ended up chewing medication, pills given in applesauce with improved swallow function, however, continued to chew larger meds. Nursing advised to crush meds in puree. Review of Resident #1's Progress Notes, dated [DATE] and written by the DON, reported The resident was seen eating lunch, up on her wheelchair. She ate 75% of lunch served. As the resident was wheeling herself away from the table, she stopped I noticed her stoic with eyes wide open. At that time, I ran to her, while the CNA closer to her immediately started the [MEDICATION NAME] maneuver. Asked if she was ok, no response noted. I swept her mouth for visible food particle, but the resident tried to bite. She (resident) was wheeled to her room by the staff, and 911 was called. No pulse felt, resident was unresponsive, CPR started. Suctioning initiated. CPR continued till paramedics arrived, at about 13:06 (1:06pm) and they took over. Review of Resident #1's Progress Notes, dated [DATE] at 16:31(4:31pm) by LVN A revealed residents' family member arrived at the facility and notified staff that resident had expired. Review of local county medical examiner report revealed Resident #1 time of death was [DATE] at 1:32PM. Cause of death is listed as Asphyxia Due to: Choking (FOOD). Review of local fire department Patient Care Record dated [DATE] revealed dispatch notified at 12:53PM of resident choking. EMS arrived at 1:01PM. Narrative: Medic was dispatched to a choking persons a call and arrived to find [AGE] year old female in [MEDICAL CONDITION] with CPR in progress. Upon arrival the patient was found lying in her nursing home facility bed unconscious and unresponsive, with her legs hanging off the end of the bed. The facilities staff was performing poor quality CPR and found holding a non-rebreather over the patients mouth flowing at 151pm. Manual chest compressions were initiated by paramedic at the time of making patient contact .The patients airway was inspected using a mac 3 blade by paramedic and a pellet of chewed carrots approximately 6cm in length and 2cm in diameter was removed from the patients airway using Magill forceps. An intubation attempt was performed as indicated above. Upon initiating respirations food had immediately begun to come up the intubation tube, suction was the initiated to attempt to remove the foreign objects. Phone interview with Paramedic on [DATE] at 1:27PM stated he was one of several responders to the [DATE] call involving Resident #1. He stated he entered Resident #1's room, and saw resident lying in bed with a backer board under her and her feet hanging off the bed. He stated there was one worker doing some CPR and another worker holding an incorrect bag over resident's mouth intended for oxygen. Paramedic stated he considered the CPR that had been delivered to Resident #1 as poor because the staff's form was not correct. He stated the staff appeared afraid to hurt resident and that she was not doing deep chest compressions. Paramedic stated that his Lieutenant removed what appeared to be a pretty solid chewed up carrots about the size of a thumb out of resident's airway. He stated the carrots were pressed baby carrots and were solid in form to where they were solid enough to stick to the forceps like a fork and remain solid through removal. He stated if the carrots were chewed up enough or a mechanical soft texture it would have been able to be mashed up upon removal but stated the carrots were solid. Paramedic stated he was not aware that Resident #1 was moved from the dining room to her room and that in his judgement resident should have not been moved and emergency services should have been done on site. Review of hospital provider notes dated [DATE] revealed HPI: Pt (Resident) was eating lunch when she choked and collapsed. CPR was started on scene. EMR arrived at 1308 (1:08pm) and pt was asystole (cardiac standstill or absence of heartbeat). CPR started by EMS. Pt (Resident) received aminophylline, [MEDICATION NAME] x2, and EPI. Pt was intubated en route. Review of Resident #1 Progress Note dated [DATE] reported resident's daughter in facility to pick up resident belonging, states resident has expired. In an interview with the ADON on [DATE] at 3:29 PM, she stated that Resident #1's family came to the facility after 2:00 PM, but before 5:00 PM. The ADON stated it was 2 women and a man; one of the two women was identified as the resident's daughter. The ADON stated the daughter asked her and RN D what Resident #1 had choked on. The ADON stated that they were unsure and did not know what the resident had eaten, so they went and asked Resident #1's table mate who told them she had only eaten two bites of carrots during that meal. Review of Provider Investigation Report dated [DATE] signed by the Administrator revealed the incident occurred on [DATE] at approximately 1:00PM when Resident #1 was found to be choking in the dining room where the [MEDICATION NAME] Maneuver was performed and resident became unresponsive. The facility did not report the incident to the state agency until three days after the incident occurred when the medical examiner confirmed cause of death to be asphyxia due to choking (FOOD). The report revealed the incident was not reported on the original date of death due to choking because clinical management at the time of transport to the ER, that Resident #1 had experienced a medical change in condition rather than choking. Review of the Menu for Friday, [DATE] reflected Baked fish Florentine, Seasoned red potatoes, parslied baby carrots, bread or roll and butter or margarine. The alternate meal was Swedish meatballs with gravy, red potatoes, parslied baby carrots, bread or roll and butter or margarine and banana cream pie with choice of beverage. Interview with CNA E on [DATE] at 1:25 PM revealed that she worked and responded to the choking incident for Resident #1 on [DATE]. CNA E stated that Resident #1 was eating (what she was eating was unknown) and right in the middle of her eating, CNA E noticed that Resident #1 started self-propelling herself in her wheelchair away from the table. CNA E approached the resident and asked if she needed anything but the resident did not respond and started waiving her hands towards her neck. CNA E stated that she asked the resident if she was choking and the resident nodded yes. CNA E stated that she then got the resident out of her wheelchair with the help of the resident and she started the [MEDICATION NAME] maneuver and yelled for help. CNA E stated that the DON responded to her call of help and the DON took over the [MEDICATION NAME]. CNA E stated that the DON was doing the [MEDICATION NAME] maneuver and she noticed that the DON put the resident back into her wheelchair. CNA E stated that the resident was fighting for air whenever the DON wheeled the resident into her room from out of the dining room. CNA E stated that she knew Resident #1 was fighting for air because she was still waving her hands towards her neck. In an interview with RN C on [DATE] at 2:10 PM, RN C stated that she was at the nurses' station charting when she heard and saw staff running towards Resident #1. She stated that she saw CNA E doing the [MEDICATION NAME] maneuver and the DON swept Resident #1's mouth, but food was not found. RN C stated that she heard the DON state she was bitten, and at that time Resident #1 was sat back into her wheelchair by the DON and wheeled to Resident #1's room. RN C stated that she knew Resident #1 was choking because her eyes were bulging and she was shaking her head yes. RN C stated that she noticed Resident #1 was not responsive whenever the resident was transferred from her wheelchair to the bed, and that the DON stated that the resident did not have a pulse and or breathing. RN C stated that CPR was started by the DON and Dietary Aide because the Dietary Aide was closest to the resident to start chest compressions. Dietary Aide provided the first round of chest compressions, and the next rounds were by RN C, then RN D and then the ADON until EMS arrived. RN C stated that best practice was to start CPR on the spot and not to move the resident because the quicker CPR is started, the better the survival rate. Interview with CNA B on [DATE] at 2:27 PM stated that she was in the dining room feeding a resident whenever she heard CNA E yelling Resident #1 was choking. CNA B stated that the DON took over the [MEDICATION NAME] and the DON put her hand in the resident's mouth where she was bitten. At that point, the resident was sat down in her wheelchair where she sat gasping for air, still choking. CNA B stated the resident was pushed to her room. In an interview with the ADON on [DATE] at 3:29 PM, she stated that she was on the B-side of the dining room whenever she heard staff yelling, She's choking!, and she then ran over and saw the DON sweeping Resident #1's mouth. She then noticed that Resident #1 was biting down and she heard a nurse say, Let's take the resident to her room, from the middle of the dining room. The ADON stated that the resident was still choking whenever she was put back into her wheelchair because her eyes were open and she was gasping for air. The ADON stated that the [MEDICATION NAME] should not have been stopped until the item came up and or the resident lost consciousness. ADON stated Resident #1 was transferred to her bed by herself, Dietary Aide, RN D, CNA B, and RN C and that at that time, resident was not responsive. The ADON stated that the DON checked for a pulse and breathing, and that there was none. The ADON stated that someone had gotten the crash cart that had emergency supplies on it, and one of those supplies was a back board that was needed so it could be placed under the resident to start CPR. The ADON stated that CPR was initiated by the DON and a Dietary Aide, and chest compressions were then completed by RN C, herself, and then another employee, whom she was unable to recall, until EMS arrived. In an interview with the DON on [DATE] at 2:49 PM, she stated that she was in the dining room feeding and eating with a resident whenever she heard CNA E yelling for help. She then ran over to Resident #1 and started a mouth sweep where she could not get in her mouth because the resident was biting down. The DON stated that she then started the [MEDICATION NAME] maneuver and tried to do another mouth sweep and the resident bit down on her finger. At that time resident was sat back down in her wheelchair. DON stated that Resident #1 was still choking whenever she was sat back down in her chair but was changing in color. The DON stated that she stopped the [MEDICATION NAME] because it was painful and hurt really bad whenever the resident bit her, and that she thought another staff had started the [MEDICATION NAME], but did not know because she left to the nurse's station to call [DATE]. DON stated the call to Emergency Services lasted a little over one minute, but no more than two minutes. She then went to Resident #1's room where the resident had been transferred to her bed. The DON stated that whenever she went to the room, she saw Dietary Aide doing chest compressions. The DON stated that she went checked Resident #1 for a pulse and for breathing, and she stated that resident did not have either. The DON stated that she got a breather bag and placed it over resident's mouth to provide oxygen while the Dietary Aide did chest compressions. The DON stated that she only provided oxygen to the resident while staff (DON was unable to recall all the staff who helped and in what order) did chest compressions. The DON stated that the resident was moved to her room for safety, and she knew they would need to do suctioning and there were no wall outlets where the resident started choking at. A joint interview on [DATE] at 1:23 PM with SLPI F and SLPI G reported that Resident #1 required close supervision with meals. SLPI F defined close supervision as one-on-one supervision while the resident ate all meals. Staff reported that anytime a resident was at risk for aspiration, it was identified on the physician orders [REDACTED]. The identified intervention was close supervision, safe swallowing techniques and checking for pocketing. SLPI G looked at Resident #1's electronic chart and stated that there were no orders for aspiration precautions in her chart, and there should have been one. In an interview with Dietary Aide A on [DATE] at 9:05 AM, she stated that she was serving in the kitchen near the nurse's station whenever she saw Resident #1 eating carrots. Dietary Aide stated that Resident #1 was served a mechanical soft diet of carrots and meatballs with gravy. Dietary Aide stated that after the incident, she observed the plate and noticed that the resident only ate a few carrots. Dietary Aide stated that she heard staff yelling and saw some running towards Resident #1. She stated that she saw the DON helping the resident by doing the [MEDICATION NAME] maneuver, and the DON put her finger into the resident's mouth, and the resident bit down on the DON's finger. The resident was then placed back into her wheelchair. Dietary Aide stated that Resident #1's, eyes were rolling back and that she acted like she could not breathe, and then everyone rolled resident in her wheelchair back to her room. Dietary Aide stated that she helped other staff put the resident in her bed, and while they were putting her in the bed she was still acting as if she could not breathe. Dietary Aide stated that the DON went to get oxygen for the resident and other items that she was unsure what they were called. Dietary Aide stated that she had gotten two paper towels to put over the resident's mouth to create a barrier. She stated that the resident had saliva coming out of her mouth, and that she just wanted to help the resident because she knew the resident was not responsive. So she tilted the resident's head back and pinched her nose and gave resident ,[DATE] breaths, provided chest pumps, and then the DON came back into the room. Dietary Aide stated that she wiped resident's mouth and she heard the DON say the resident was not responsive, so the DON put a mask over the resident's mouth and then Dietary Aide gave a round of chest compressions. Someone else then started giving chest pumps while the DON gave the resident oxygen. Dietary Aide stated that there were nurses in the room, but she just wanted to save the resident's life because everyone was helping with something. She said she was not trained and or certified to provide CPR, and that she was trying to help resident. Dietary Aide stated that she was unsure how long it took for CPR to get started or who was in the room at that time. In an interview with RN D on [DATE] at 1:46 PM, she stated that that she was on the phone whenever she heard someone yelling for help. RN D stated that she went with other staff to Resident #1's room to see what she could help with, and that she helped staff transfer the resident from her wheelchair to her bed. At that point, Resident #1 was unresponsive, and that she knew she was because once the resident was on the bed, RN D called the resident by name she touched, and shook resident, but there was no response from her. RN D stated that followed by that, the DON entered into the room and checked the resident's pulse and to see if she was breathing, and there was nothing noted. RN D stated that CPR was started by Dietary Aide and the DON. She stated the DON provided oxygen to the resident while tilting the resident's head back, and the Dietary Aide did chest compressions. RN D stated that Dietary Aide did CPR first because she was closest to resident. RN D stated that CPR was started within two minutes of the resident becoming unresponsive. RN D stated that CPR should have been done on site in the dining room and the resident should have not been moved to her room. In an interview with the ED on [DATE] at 6:24 PM, he stated that his clinical department responded to Resident #1 appropriately. The ED stated that although the resident was moved from the dining room to her room, he was informed that an unresponsive person can go up to five minutes without CPR before damages can occur. The ED stated that he paced it himself, and where the incident happed to Resident #1's room location was only ,[DATE] steps. He stated that he did not account for how long it took staff to transfer resident to her bed and to get back board under her. ED stated that the process his staff took he considered it an immediate response. Review of Resident Council Minutes, dated [DATE], reported vegetables sometimes too hard to chew. There was no subsequent Resident Council Minutes. There was no documentation that issue was addressed by the facility. Review of Emergency Procedure for Choking, dated [DATE], reflected the following: .4. Call for help, but stay with the resident. .5. Quickly assure the resident that you are going to stay and assist him or her. .6. If the resident cannot cough, only then should abdominal thrusts be performed . .h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Review of A step-by-step guide explaining what to do in a choking emergency, obtained on [DATE] from https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637, reflected the following: To clear the airway of an unconscious person: Lower the person on his or her back onto the floor, arms to the side. Clear the airway. If a blockage is visible at the back of the throat or high in the throat, reach a finger into the mouth and sweep out the cause of the blockage. Don't try a finger sweep if you can't see the object. Be careful not to push the food or object deeper into the airway, which can happen easily in young children. Begin CPR if the object remains lodged and the person doesn't respond after you take the above measures. The chest compressions used in CPR may dislodge the object. Remember to recheck the mouth periodically. Review of Policy Emergency Procedure-Cardiopulmonary Resuscitation, dated [DATE], reported the following: .5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. .6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. .8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advances Life Support (ALS). .9. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: .a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exits for that individual; or .b. There are obvious signs of irreversible death. An Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:17 PM. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 2:58 PM. The Plan of Removal reflected: In their discussion with the facility, HHSC stated alleged that the facility created an Immediate Jeopardy condition by: 1. The facility discontinued the [MEDICATION NAME] Maneuver after 2 unsuccessful attempts to dislodge food that the resident was choking on. Company Policy and Procedure dictates that the maneuver continue until either the foreign object is dislodged, or until the person becomes unconscious. 2. Initial CPR was begun by a Dietary Aide who is not certified on CPR despite multiple nurses and nurse aides being present in the room. The facility identified the following residents as being at risk of aspiration; Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8. All resident records have been audited to identify any other residents at risk for aspiration. None were found. This audit was completed immediately [DATE] by facility ADON. These residents were identified from the eMar based on a [DIAGNOSES REDACTED]. .The first step the facility will take to remove the immediacy, will be to inservice all clinical and dietary staff currently at the facility, including the DON, on the P&P (policy and procedure) regarding continuing the [MEDICATION NAME] Maneuver until the resident has passed out or until the foreign object is removed. This inservice is currently being done by (RN I), and (Senior Nurse Consultant) for (the facility). Any PRN staff or any staff currently on leave will be inserviced prior to returning to work. Competency drills will be done on medical emergency response drills, (cardiac and respiratory), weekly times 4 and monthly times 3. Drills will be monitored by the regional nurse. The drills will be evaluated for staff performance with appropriate counseling and retaining as needed. Inservices on Abuse and Neglect will be conducted by Executive Director or designee. Source documentation will be Abuse/Neglect Policies and Procedures. This training will include all facility staff. The facility will validate CPR and [MEDICATION NAME] competency via return demonstration with all licensed staff, whether currently certified or not. This will begin taking place on-site on [DATE] by certified BLS trainers from outside (the facility). Anticipated completion [DATE]. Clinical staff will not be allowed to provide care for any of the above identified at-risk residents until they have attended the inservice. CPR will only be done by staff who are certified. For purposes of this plan, only licensed clinical staff will participate in the competency testing. The seven residents identified as being at risk will be observed during meal service by licensed nurses, for signs of aspiration. The food service supervisor will monitoring food service to make sure that those seven residents' modified diets are served as ordered by physician. The food service manager will submit weekly reports of observations. No licensed staff will be allowed to work until their CPR certification is verified. Dietary staff have been instructed not to do CPR. The facility will immediately add a note to each med cart of the residents at risk for aspiration. This was done on [DATE]. An alert will be added to the eMar for every resident on the list for at risk for aspiration precautions. This was done [DATE]. Monitoring interviews were conducted at various times on [DATE] with staff the following staff: CNA E, CNA F, CAN G, CNA H, CNA J, CNA B, CNA K, LVN L, LVN M, RN D, RN N, DON, ADON, RN M. Staff interviewed were representative of various facility shifts. Staff was able to provide return demonstration and competency regarding training over the [MEDICATION NAME] Maneuver and CPR and competency regarding abuse and neglect. CMS Form 672 signed and dated by the DON on [DATE] revealed resident census of 63.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency (DADS)) and to have evidence that alleged violations were thoroughly investigated for one resident (Resident #6) of 18 residents reviewed for abuse and neglect. 1. LVN E and the Weekend Supervisor (RN RR) failed to immediately report a bruise of unknown source to the Administrator when it was discovered on 09/12/15 for Resident #6, who had limited movement and required the extensive assistance of staff. The resident was found with a black eye (bruise) to her left eye on 09/12/15. 2. ADON A failed to immediately notify the Administrator and the DON when she learned about Resident #6's bruise of unknown source on 09/14/15. 3. The Administrator and DON failed to report Resident #6's black eye/bruise of unknown origin to the State certification agency once they made aware on 09/16/15. An Immediate Jeopardy (IJ) was identified on 09/18/15. While the IJ was removed on 09/20/15, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect all 88 residents by placing them at risk for mistreatment, abuse, and/or neglect by facility staff. Findings included: Resident #6's MDS assessment, dated 06/22/15, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with her ADLs to include bed mobility, transfer, and personal hygiene. The resident had functional limitation in range of motion to her bilateral upper and lower extremities. An observation on 09/16/15 at 7:55 a.m. revealed Resident #6 lying in bed. The resident had a black eye (dark purple bruise) to her left eye measuring approximately 2.0 cm x 3.0 cm. The resident's hands and neck were contracted. LVN D, who was present during this observation, stated Resident #6's cognition was poor, and the resident was unable to speak, except to say uh huh (yes) and uh uh (no) when asked simple questions. LVN D stated Resident #6 required the assistance of two staff with dressing, bathing, toileting, and transfer by Hoyer lift daily to her wheelchair. She explained that the resident's left hand and neck were contracted, and the resident was incontinent of bowel and bladder, and she had contractures in her left hand and her neck. She added that the resident's skin was easily bruised. An interview on 09/18/15 at 3:15 p.m. with Resident #6, with the resident's family present, revealed the only intelligible or distinguishable answer was an uh huh (yes) when asked if the bruise occurred when she was in her chair. The resident did not answer intelligibly when asked if anyone had hurt her, if the injury occurred in her bed or chair, or if her face bruised when she was rolled into the side rail protector. Resident #6's family stated they thought the resident probably could not remember the incident now. An electronic Event Report, created by LVN E on 09/12/15 at 4:16 p.m., reflected Resident #6 had a light purple bruise to her left eye measuring 2.0 cm x 4.0 cm on 09/12/15 at 3:15 p.m. An attached Investigation Report, completed by LVN E on 09/12/15, reflected Resident #6 had a bruise. LVN E documented, I asked resident (Resident #6) is she knew what happened. Stated No. The report was signed by ADON A and ADON B on 09/14/15. A typed statement, dated 09/15/15, from ADON A reflected she asked Resident #6 what happened to cause the bruise to the resident's left eye, and the resident was not able to verbalize what happened. A handwritten statement, dated 09/12/15, from CNA J reflected she assisted CNA L transfer Resident #6 using a Hoyer lift on 09/12/15 at 3:00 p.m. During that transfer, she documented, I noticed that she (Resident #6) had a small bruise under her left eye, after we transferred (sic) her. An interview on 09/18/15 at 11:16 a.m. with CNA J revealed she helped CNA L transfer Resident #6 with the Hoyer lift from bed to chair of Resident #6 on 09/12/15. CNA J stated she noticed the bruise under Resident #6's left eye, and she mentioned it to CNA L. She stated she did not know the cause of the bruise. A handwritten statement, dated 09/15/15, from CNA L reflected he provided care to Resident #6 on 09/12/15 with the assistance of CNA J and CNA U. CNA L documented, I never observed or noticed any bruise on the resident's (Resident #6) face till it was brought to my attention by the nurse in charge . An interview on 09/19/15 at 1:20 p.m. with CNA L revealed he worked with Resident #6 on 09/12/15 from 6:00 a.m. to 10:00 p.m. CNA L stated he turned the resident from side to side with assistance from CNA J when the resident's brief was changed and the resident was dressed. CNA L stated he did not notice a bruise on her face, and he stated the resident's face did not come close to the side rails during care. A typed statement, dated 09/14/15, from RN S reflected she assisted a CNA transfer Resident #6 on 09/12/15 around 6:45 p.m. when she noticed some purple discoloration on the resident's left eye. RN S asked Resident #6 what happened to her eye, and the resident shook her head and said she did not know. Resident Progress Notes, entered by LVN E on 09/12/15 at 3:15 p.m., reflected: Bruise light purple color below left eye observed. N/C (no complaints) of pain. (Family members) visiting with resident, up to W/C (wheelchair). Resident on Aspirin 81 mg daily. An interview on 09/18/15 at 11:26 a.m. with LVN E revealed she was the charge nurse for Resident #6 on 09/12/15, when the bruise to Resident #6's left eye was discovered. The report given to her from the 11:00 p.m. to 7:00 a.m. staff did not mention a bruise under Resident #6's eye. She stated Resident #6's family member came to her on 09/12/15 around 3:00 p.m. and reported that Resident #6 had a bruise under her left eye. LVN E stated she went to Resident #6's room and conducted a physical assessment, and she asked the resident if she was hurting. She stated the resident said uh uh which she interpreted as (no). She stated she asked the CNAs what had happened, and they all stated they did not know the cause of the bruise. She stated she then notified the Physician and the Weekend Supervisor, RN RR, of the bruise. LVN E stated she then charted the event in Resident #6's clinical record, and she began the investigation by interviewing staff. An interview on 09/18/15 at 3:55 p.m. with RN RR revealed she was aware of Resident #6's bruise the weekend of 09/12/15. She knew that an investigation was being done. She stated on 09/12/15 (Saturday) the bruise was not very dark, but it got darker on 09/13/15 (Sunday). She stated she did not mention the bruise to ADON A when she talked to her on the weekend of 09/12-09/13/15. RN RR stated she also did not notify the DON or Administrator about the bruise. She stated the protocol was to report a bruise of unknown injury to the DON and Abuse Coordinator (Administrator) as soon as it was discovered. RN RR stated on 09/14/15 (Monday) Resident #6's family member asked what had been discovered regarding the bruise, and ADON A read her the Event Report. An interview on 09/18/15 at 3:45 p.m. with ADON A revealed RN RR was aware of Resident #6's bruise during the weekend of 09/12-09/13/15, but RN RR did not mention it to her. ADON A stated RN RR was working on the floor during the weekend, and this must have distracted her. ADON A was asked what the facility protocol for incidents involving unwitnessed or suspicious injuries. She stated staff should complete an incident report, notify the physician, family, the manager on duty, and the Administrator (Abuse Coordinator) right away, and the state should be called within 24 hours. An interview on 09/18/15 at 2:58 p.m. with the Administrator, who was the designated Abuse Prohibition Coordinator, revealed she would not have reported Resident #6's bruise to DADS. She explained she did not report the incident involving Resident #6 having a bruise to her left eye because she believed the bruise occurred when the resident was turned. The Administrator stated she knew the DON conducted an investigation including an interview with Resident #6, who responded positively when asked if the bruise occurred while she was being turned. The Administrator stated because of the interview, she believed the injury was not of unknown origin. She acknowledged the incident was not witnessed. When asked if a injury of unknown origin like a bruise was reported to her today would she report it to DADS, she stated she would not report it if they could come up with a possible explanation or cause of the injury. An interview on 09/18/15 at 11:50 a.m. with the DON revealed she was notified of the incident on 09/16/15, and she conducted her own investigation. She stated the incident involving Resident #6's facial bruise had not been reported to DADS. The DON was asked why the incident was not reported to DADS, and her response was that the resident's bruise was known. After reviewing Resident #6's care and routine, the DON stated she concluded the bruise must have happened when the resident was turned during care because of the closeness of her face to the side rail protector. She was asked if anyone witnessed that, and she said no. She stated she interviewed the resident, with the resident's family member present, if someone hurt her on purpose. The DON revealed Resident #6 answered uh uh, which she interpreted as no. She stated she then asked Resident #6 if the bruise on her eye happened when staff turned her during care, and the resident answered uh huh, which she interpreted as yes. During the interview, the DON provided a copy of DADS Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported (Replaces PL 06 -43) dated 08/19/14. She revealed since Resident #6 could give an account of how the bruise happened, it was a known injury and did not have to be reported within 24 hours. Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported (Replaces PL 06-43) dated 08/19/14 reflected under Reporting Abuse, Neglect, Exploitation and Other Incidents reflected the following: .8. SUSPICIOUS INJURIES OF UNKNOWN SOURCE (injuries of unknown source are defined in CMS Survey & Certification (S&C) 05-09). An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: · The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, · The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Interviews on 09/18/15 at 11:26 a.m. with LVN E, RN RR at 3:55 p.m., ADON A at 3:45 p.m., the DON at 11:50 a.m., and the Administrator at 2:58 p.m. revealed there were no witnesses to the incident that caused the bruise to Resident #6's left eye. The facility's current, undated Abuse Prevention and Prohibition policy and procedure reflected the following: .IDENTIFICATION OF POSSIBLE INCIDENTS AND ALLEGATIONS 1. All employees are responsible for monitoring resident for possible signs of abuse. Methods of identification may include but are not limited to: .c. Reports made to the charge nurse or administrative staff member, residents, family members or visitors in regards to: .i. Unusual body marks in the resident .INVESTIGATION 1. The facility will always conduct an investigation of any allegation of abuse, neglect . 2. The investigation will be conducted according to State and Federal Guidelines by the Administrator, Director of Nursing, Abuse Prevention Coordinator and or other designee, and the .Police Department, if appropriate. a. The investigation will consist of, but not be limited to: .i. Resident assessment ii. Staff interviews iii. Family interviews iv. Roommate /hall mate interviews b. All interviews must be done in person, if possible. c. All steps of the investigation should be documented, including: i. Actions taken as a result of the investigation ii. Corrective actions taken to prevent the recurrence of the incident. d. The results of the investigation must be submitted to the Administrator. .REPORTING/RESPONSE 1. Staff must always report abuse immediately to the charge nurse and/or administration. .3. Incidents will be reported to the Texas Department of Human Services (DADS) in accordance with the guidelines contained in the current Provider Letter of the State Further review of the facility's Abuse Prevention and Prohibition policy and procedure revealed the policy did not address injuries of unknown source. An IJ was identified on 09/18/15. The Administrator, the DON, and the Medical Director were informed of the IJ on 09/18/15 at 4:29 p.m. A Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 09/20/15 at 4:11 p.m., reflected the following: .A skin assessment was completed on 9/18/2015 by ADON B, RN JJ and LVN UU. .Provider Investigation Report filed 5:30 p.m. on 9/18/2015 by the DON .Investigation of abuse was not substantiated and completed by ADON A on 9/15/2015 .A house wide audit of resident's skin status was completed by nurse managers on 9/18/2015 to identify suspicious bruising or other concerns of abuse. Skin Assessments completed by RN JJ, ADON B, LVN UU, RN S, LVN WW, LVN XX, RN YY. · Resident who are dependent and have a side rail were re-assessed for the device to ensure benefits are greater than risks (residents and responsible party will be involved in recommendations) - assessments were completed on 09/19/15 at 300 (p.m.). · All suspicious areas of unknown origin identified during the chart audits including event reports were reported within 24 hours to DADS according to (facility's) policy and procedure. Resident #1 totally dependent, skin tear right shin reported Resident #2 totally dependent, bruise right thigh Resident #3 totally dependent, bruise right thigh Resident #4 totally dependent, bruise right knee .Education was conducted by Senior Nurse Consultant. 9/18/2015 - Administrator and DON received education by RN Senior Nurse Consultant related to reporting responsibilities of all suspicious bruises, allegations of abuse upon notification (within 24 hours) followed by an investigation. Reporting to Department of Aging and Disabilities Services. Responsibility of educating staff at all levels and ensuring adherence to the Abuse Policies. Reporting to the Director of Management, Nurse Consultant, and Senior Nurse Consultant to ensure compliance with reporting policies and compliance to those policies. Nursing Supervisor (RN RR) was provided education by Senior Nurse Consultant (Senior RN Consultant) on 9/18/2015. DON conducted employee counseling on 9/19/2015. .Education was provided to nurse managers related to resident right to be free from abuse and also reporting responsibilities of health facility employees related to abuse and crime. Safety of resident/residents, removal of the perpetrator/perpetrators while conducting an investigation, and reporting the allegation of abuse to the Executive Director/abuse coordinator immediately. A verbal quiz was conducted with participants to validate understanding and competency. .Education was provided to employees (line staff /direct care givers - both licensed and non-licensed working on the evening and nights shifts on 9/18/2015 and day shift on 9/19/2015. Safety of resident/residents, removal of the perpetrator/ perpetrators while conducting an investigation, and reporting the allegation of abuse to the Executive Director /abuse coordinator immediately. A verbal quiz was conducted with participants to validate understanding and competency. · Daily rounds will be conducted by Nurse Managers and or nurse supervisor to ensure allegations of abuse and reporting responsibilities are understood by Licensed and non-licensed staff on-going. Questioning staff and interviewing and observing residents in a manor to support the safety of residents. · All employees will attend abuse training and have competency validated. · A notice posted at the time clock to remain in the break room upon clocking in for the shift - where education and competency validation will occur for all employees. · Employees working with direct resident care will receive education prior to reporting to the resident care area and must verbalize understanding of the responsibilities to identify and report abuse or allegations of abuse. · Supervisors will understand the responsibility to identify, report and then investigate abuse and or allegations of abuse following the policies and procedures. Education will be completed on all employees in each department prior to working a scheduled shift. Employees will not work until they have completed Abuse and Resident Rights and can verbally demonstrate competence of identification of abuse, when to report, resident safety and who to report to. .The Administrator has a 24 hour a day 7 days a week 365 days a year phone number posted at each nurses station and in the break room for employees. Completion date Sunday September 19, at 2400 (midnight, 12:00 a.m.). An observation on 09/19/15 at 9:50 a.m. revealed the Senior RN Consultant providing an in-service to staff. Nine staff members were in attendance, and the in-service was interactive and required participation by staff members to verify understanding. In addition, staff members were given the facility's policy and procedure on abuse and neglect and copies appeared at the nurses' station and in common areas where employees congregated. An interview on 09/19/15 at 1:32 p.m. with the DON revealed the major failure was of RN RR to report the incident to the DON and Administrator. She stated there was a lack of communication between staff and administration. The DON stated in-services on abuse/neglect and dependent care were conducted with all staff on paydays. Regarding injuries of unknown origin, the DON stated all staff should report these to the supervisor, who should then begin an investigation. She stated incidents should also be reported to the DON and then to the Administrator. An interview on 09/19/15 at 1:20 p.m. with the Administrator revealed the factors contributing to the IJ situation were a system failure when RN RR did not follow the facility's policy and procedure for reporting incidents. She stated if the incident had been reported to the DON and Administrator, the approach and investigation would have been different. The Administrator stated all staff would receive in-service training regarding abuse/neglect. Also, the facility's system would be monitored at daily stand-up meetings to include going over any and all concerns with department heads to make sure they were being addressed. She stated any issues were taken to QA meetings. Interviews were conducted on 09/20/15 from 10:45 a.m. through 3:30 p.m. with the following facility staff members, who represented staff from all three shifts: CNA Q, MA R, MA TT, RN S, RN JJ, LVN E, LVN GG, LVN LL, LVN D, Housekeeper T, CNA U, CNA V, Housekeeper W, CNA X, CNA Y, LVN Z, Cook AA, Dietary BB, Dietary CC, MA DD, Dietary EE, CNA MM, Dietary NN, RN RR, LVN OO, CNA ZZ, and CNA AAA. These interviews revealed staff members received in-service training on abuse, neglect and exploitation. The staff members were able to provide specific examples of suspicious injuries, such as bruising or discoloration on the face, neck or around the perineal area and upper thigh. The staff members were able to discuss what circumstances would require them to notify the charge nurse and the Administrator immediately. They identified any resident change in behavior such as change in personality, fear or guarding around a specific staff member, different behavior such as crying, refusing care or services as potential indications for possible abuse and neglect which would be reported to the Administrator. They were able to state that the Administrator was the facility's Abuse Prohibition Coordinator and how she could be reached. They were able to verbalize what needed to be reported and to whom they should make the report. The IJ was removed on 09/20/15 at 4:11 p.m The Administrator and the DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 09/16/15, reflected the facility census was 88.

Based on observation, interview and record, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for one (Resident #6) of 18 residents reviewed for abuse and neglect. 1. LVN E and the Weekend Supervisor (RN RR) failed to immediately report Resident #6's bruising and swelling of unknown source under her left eye to the Administrator when it was discovered on 09/12/15. 2. ADON A failed to immediately notify the Administrator and the DON when she learned about it on 09/14/15. 3. The Administrator and DON failed to report Resident #6's bruising and swelling of unknown origin to the State survey and certification agency (DADS) once they made aware on 09/16/15. An Immediate Jeopardy (IJ) was identified on 09/18/15. While the IJ was removed on 09/20/15, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect all 88 residents by placing them at risk for mistreatment, abuse, and/or neglect by facility staff. Findings included: The facility's current, undated Abuse Prevention and Prohibition policy and procedure reflected the following: .IDENTIFICATION OF POSSIBLE INCIDENTS AND ALLEGATIONS 1. All employees are responsible for monitoring resident for possible signs of abuse. Methods of identification may include but are not limited to: .c. Reports made to the charge nurse or administrative staff member, residents, family members or visitors in regards to: .i. Unusual body marks in the resident .INVESTIGATION 1. The facility will always conduct an investigation of any allegation of abuse, neglect . 2. The investigation will be conducted according to State and Federal Guidelines by the Administrator, Director of Nursing, Abuse Prevention Coordinator and or other designee, and the .Police Department, if appropriate. a. The investigation will consist of, but not be limited to: .i. Resident assessment ii. Staff interviews iii. Family interviews iv. Roommate /hall mate interviews b. All interviews must be done in person, if possible. c. All steps of the investigation should be documented, including: i. Actions taken as a result of the investigation ii. Corrective actions taken to prevent the recurrence of the incident. d. The results of the investigation must be submitted to the Administrator. .REPORTING/RESPONSE 1. Staff must always report abuse immediately to the charge nurse and/or administration. .3. Incidents will be reported to the Texas Department of Human Services (DADS) in accordance with the guidelines contained in the current Provider Letter of the State Further review of the facility's Abuse Prevention and Prohibition policy and procedure revealed the policy did not address injuries of unknown source. Resident #6's MDS assessment, dated 06/22/15, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with her ADLs to include bed mobility, transfer, and personal hygiene. The resident had functional limitation in range of motion to her bilateral upper and lower extremities. An observation on 09/16/15 at 7:55 a.m. revealed Resident #6 lying in bed. The resident had black eye (dark purple bruise) to her left eye measuring approximately 2.0 cm x 3.0 cm. The resident's hands and neck were contracted. LVN D, who was present during this observation, stated Resident #6's cognition was poor, and the resident was unable to speak, except to say uh huh (yes) and uh uh (no) when asked simple questions. LVN D stated Resident #6 required the assistance of two staff with dressing, bathing, toileting, and transfer by Hoyer lift daily to her wheelchair. She explained that the resident's left hand and neck were contracted, and the resident was incontinent of bowel and bladder, and she had contractures in her left hand and her neck. She added that the resident's skin was easily bruised. An interview on 09/18/15 at 3:15 p.m. with Resident #6, with the resident's family present, revealed the only intelligible or distinguishable answer was an uh huh (yes) when asked if the bruise occurred when she was in her chair. The resident did not answer intelligibly when asked if anyone had hurt her, if the injury occurred in her bed or chair, or if her face bruised when she was rolled into the side rail protector. Resident #6's family stated they thought the resident probably could not remember the incident now. An electronic Event Report, created by LVN E on 09/12/15 at 4:16 p.m., reflected Resident #6 had a light purple bruise to her left eye measuring 2.0 cm x 4.0 cm on 09/12/15 at 3:15 p.m. An attached Investigation Report, completed by LVN E on 09/12/15, reflected Resident #6 had a bruise. LVN E documented, I asked resident (Resident #6) is she knew what happened. Stated No. The report was signed by ADON A and ADON B on 09/14/15. A typed statement, dated 09/15/15, from ADON A reflected she asked Resident #6 what happened to cause the bruise to the resident's left eye, and the resident was not able to verbalize what happened. A handwritten statement, dated 09/12/15, from CNA J reflected she assisted CNA L transfer Resident #6 using a Hoyer lift on 09/12/15 at 3:00 p.m. During that transfer, she documented, I noticed that she (Resident #6) had a small bruise under her left eye, after we transferred (sic) her. An interview on 09/18/15 at 11:16 a.m. with CNA J revealed she helped CNA L transfer Resident #6 with the Hoyer lift from bed to chair of Resident #6 on 09/12/15. CNA J stated she noticed the bruise under Resident #6's left eye, and she mentioned it to CNA L. She stated she did not know the cause of the bruise. A handwritten statement, dated 09/15/15, from CNA L reflected he provided care to Resident #6 on 09/12/15 with the assistance of CNA J and CNA U. CNA L documented, I never observed or noticed any bruise on the resident's (Resident #6) face till it was brought to my attention by the nurse in charge . An interview on 09/19/15 at 1:20 p.m. with CNA L revealed he worked with Resident #6 on 09/12/15 from 6:00 a.m. to 10:00 p.m. CNA L stated he turned the resident from side to side with assistance from CNA J when the resident's brief was changed and the resident was dressed. CNA L stated he did not notice a bruise on her face, and he stated the resident's face did not come close to the side rails during care. A typed statement, dated 09/14/15, from RN S reflected she assisted a CNA transfer Resident #6 on 09/12/15 around 6:45 p.m. when she noticed some purple discoloration on the resident's left eye. RN S asked Resident #6 what happened to her eye, and the resident shook her head and said she did not know. Resident Progress Notes, entered by LVN E on 09/12/15 at 3:15 p.m., reflected: Bruise light purple color below left eye observed. N/C (no complaints) of pain. (Family members) visiting with resident, up to W/C (wheelchair). Resident on Aspirin 81 mg daily. An interview on 09/18/15 at 11:26 a.m. with LVN E revealed she was the charge nurse for Resident #6 on 09/12/15, when the bruise to Resident #6's left eye was discovered. The report given to her from the 11:00 p.m. to 7:00 a.m. staff did not mention a bruise under Resident #6's eye. She stated Resident #6's family member came to her on 09/12/15 around 3:00 p.m. and reported that Resident #6 had a bruise under her left eye. LVN E stated she went to Resident #6's room and conducted a physical assessment, and she asked the resident if she was hurting. She stated the resident said uh uh which she interpreted as (no). She stated she asked the CNAs what had happened, and they all stated they did not know the cause of the bruise. She stated she then notified the Physician and the Weekend Supervisor, RN RR, of the bruise. LVN E stated she then charted the event in Resident #6's clinical record, and she began the investigation by interviewing staff. An interview on 09/18/15 at 3:55 p.m. with RN RR revealed she was aware of Resident #6's bruise the weekend of 09/12/15. She knew that an investigation was being done. She stated on 09/12/15 (Saturday) the bruise was not very dark, but it got darker on 09/13/15 (Sunday). She stated she did not mention the bruise to ADON A when she talked to her on the weekend of 09/12-09/13/15. RN RR stated she also did not notify the DON or Administrator about the bruise. She stated the protocol was to report a bruise of unknown injury to the DON and Abuse Coordinator (Administrator) as soon as it was discovered. RN RR stated on 09/14/15 (Monday) Resident #6's family member asked what had been discovered regarding the bruise, and ADON A read her the Event Report. An interview on 09/18/15 at 3:45 p.m. with ADON A revealed RN RR was aware of Resident #6's bruise during the weekend of 09/12-09/13/15, but RN RR did not mention it to her. ADON A stated RN RR was working on the floor during the weekend, and this must have distracted her. ADON A was asked what the facility protocol for incidents involving unwitnessed or suspicious injuries. She stated staff should complete an incident report, notify the physician, family, the manager on duty, and the Administrator (Abuse Coordinator) right away, and the state should be called within 24 hours. An interview on 09/18/15 at 2:58 p.m. with the Administrator, who was the designated Abuse Prohibition Coordinator, revealed she would not have reported Resident #6's bruise to DADS. She explained she did not report the incident involving Resident #6 having a bruise to her left eye because she believed the bruise occurred when the resident was turned. The Administrator stated she knew the DON conducted an investigation including an interview with Resident #6, who responded positively when asked if the bruise occurred while she was being turned. The Administrator stated because of the interview, she believed the injury was not of unknown origin. She acknowledged the incident was not witnessed. When asked if a injury of unknown origin like a bruise was reported to her today would she report it to DADS, she stated she would not report it if they could come up with a possible explanation or cause of the injury. An interview on 09/18/15 at 11:50 a.m. with the DON revealed she was notified of the incident on 09/16/15, and she conducted her own investigation. She stated the incident involving Resident #6's facial bruise had not been reported to DADS. The DON was asked why the incident was not reported to DADS, and her response was that the resident's bruise was known. After reviewing Resident #6's care and routine, the DON stated she concluded the bruise must have happened when the resident was turned during care because of the closeness of her face to the side rail protector. She was asked if anyone witnessed that, and she said no. She stated she interviewed the resident, with the resident's family member present, if someone hurt her on purpose. The DON revealed Resident #6 answered uh uh, which she interpreted as no. She stated she then asked Resident #6 if the bruise on her eye happened when staff turned her during care, and the resident answered uh huh, which she interpreted as yes. During the interview, the DON provided a copy of DADS Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported (Replaces PL 06 -43) dated 08/19/14. She revealed since Resident #6 could give an account of how the bruise happened, it was a known injury and did not have to be reported within 24 hours. Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported (Replaces PL 06-43) dated 08/19/14 reflected under Reporting Abuse, Neglect, Exploitation and Other Incidents reflected the following: .8. SUSPICIOUS INJURIES OF UNKNOWN SOURCE (injuries of unknown source are defined in CMS Survey & Certification (S&C) 05-09). An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: · The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, · The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Interviews on 09/18/15 at 11:26 a.m. with LVN E, RN RR at 3:55 p.m., ADON A at 3:45 p.m., the DON at 11:50 a.m., and the Administrator at 2:58 p.m. revealed there were no witnesses to the incident that caused the bruise to Resident #6's left eye. An IJ was identified on 09/18/15. The Administrator, the DON, and the Medical Director were informed of the IJ on 09/18/15 at 4:29 p.m. A Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 09/20/15 at 4:11 p.m., reflected the following: .A skin assessment was completed on 9/18/2015 by ADON B, RN JJ and LVN UU. .Provider Investigation Report filed 5:30 p.m. on 9/18/2015 by the DON .Investigation of abuse was not substantiated and completed by ADON A on 9/15/2015 .A house wide audit of resident's skin status was completed by nurse managers on 9/18/2015 to identify suspicious bruising or other concerns of abuse. Skin Assessments completed by RN JJ, ADON B, LVN UU, RN S, LVN WW, LVN XX, RN YY. · Resident who are dependent and have a side rail were re-assessed for the device to ensure benefits are greater than risks (residents and responsible party will be involved in recommendations) - assessments were completed on 09/19/15 at 300 (p.m.). · All suspicious areas of unknown origin identified during the chart audits including event reports were reported within 24 hours to DADS according to (facility's) policy and procedure. Resident #1 totally dependent, skin tear right shin reported Resident #2 totally dependent, bruise right thigh Resident #3 totally dependent, bruise right thigh Resident #4 totally dependent, bruise right knee .Education was conducted by Senior Nurse Consultant. 9/18/2015 - Administrator and DON received education by RN Senior Nurse Consultant related to reporting responsibilities of all suspicious bruises, allegations of abuse upon notification (within 24 hours) followed by an investigation. Reporting to Department of Aging and Disabilities Services. Responsibility of educating staff at all levels and ensuring adherence to the Abuse Policies. Reporting to the Director of Management, Nurse Consultant, and Senior Nurse Consultant to ensure compliance with reporting policies and compliance to those policies. Nursing Supervisor (RN RR) was provided education by Senior Nurse Consultant (Senior RN Consultant) on 9/18/2015. DON conducted employee counseling on 9/19/2015. .Education was provided to nurse managers related to resident right to be free from abuse and also reporting responsibilities of health facility employees related to abuse and crime. Safety of resident/residents, removal of the perpetrator/perpetrators while conducting an investigation, and reporting the allegation of abuse to the Executive Director/abuse coordinator immediately. A verbal quiz was conducted with participants to validate understanding and competency. .Education was provided to employees (line staff /direct care givers - both licensed and non-licensed working on the evening and nights shifts on 9/18/2015 and day shift on 9/19/2015. Safety of resident/residents, removal of the perpetrator/ perpetrators while conducting an investigation, and reporting the allegation of abuse to the Executive Director /abuse coordinator immediately. A verbal quiz was conducted with participants to validate understanding and competency. · Daily rounds will be conducted by Nurse Managers and or nurse supervisor to ensure allegations of abuse and reporting responsibilities are understood by Licensed and non-licensed staff on-going. Questioning staff and interviewing and observing residents in a manor to support the safety of residents. · All employees will attend abuse training and have competency validated. · A notice posted at the time clock to remain in the break room upon clocking in for the shift - where education and competency validation will occur for all employees. · Employees working with direct resident care will receive education prior to reporting to the resident care area and must verbalize understanding of the responsibilities to identify and report abuse or allegations of abuse. · Supervisors will understand the responsibility to identify, report and then investigate abuse and or allegations of abuse following the policies and procedures. Education will be completed on all employees in each department prior to working a scheduled shift. Employees will not work until they have completed Abuse and Resident Rights and can verbally demonstrate competence of identification of abuse, when to report, resident safety and who to report to. .The Administrator has a 24 hour a day 7 days a week 365 days a year phone number posted at each nurses station and in the break room for employees. Completion date Sunday September 19, at 2400 (midnight, 12:00 a.m.). An observation on 09/19/15 at 9:50 a.m. revealed the Senior RN Consultant providing an in-service to staff. Nine staff members were in attendance, and the in-service was interactive and required participation by staff members to verify understanding. In addition, staff members were given the facility's policy and procedure on abuse and neglect and copies appeared at the nurses' station and in common areas where employees congregated. An interview on 09/19/15 at 1:32 p.m. with the DON revealed the major failure was of RN RR to report the incident to the DON and Administrator. She stated there was a lack of communication between staff and administration. The DON stated in-services on abuse/neglect and dependent care were conducted with all staff on paydays. Regarding injuries of unknown origin, the DON stated all staff should report these to the supervisor, who should then begin an investigation. She stated incidents should also be reported to the DON and then to the Administrator. An interview on 09/19/15 at 1:20 p.m. with the Administrator revealed the factors contributing to the IJ situation were a system failure when RN RR did not follow the facility's policy and procedure for reporting incidents. She stated if the incident had been reported to the DON and Administrator, the approach and investigation would have been different. The Administrator stated all staff would receive in-service training regarding abuse/neglect. Also, the facility's system would be monitored at daily stand-up meetings to include going over any and all concerns with department heads to make sure they were being addressed. She stated any issues were taken to QA meetings. Interviews were conducted on 09/20/15 from 10:45 a.m. through 3:30 p.m. with the following facility staff members, who represented staff from all three shifts: CNA Q, MA R, MA TT, RN S, RN JJ, LVN E, LVN GG, LVN LL, LVN D, Housekeeper T, CNA U, CNA V, Housekeeper W, CNA X, CNA Y, LVN Z, Cook AA, Dietary BB, Dietary CC, MA DD, Dietary EE, CNA MM, Dietary NN, RN RR, LVN OO, CNA ZZ, and CNA AAA. These interviews revealed staff members received in-service training on abuse, neglect and exploitation. The staff members were able to provide specific examples of suspicious injuries, such as bruising or discoloration on the face, neck or around the perineal area and upper thigh. The staff members were able to discuss what circumstances would require them to notify the charge nurse and the Administrator immediately. They identified any resident change in behavior such as change in personality, fear or guarding around a specific staff member, different behavior such as crying, refusing care or services as potential indications for possible abuse and neglect which would be reported to the Administrator. They were able to state that the Administrator was the facility's Abuse Prohibition Coordinator and how she could be reached. They were able to verbalize what needed to be reported and to whom they should make the report. The IJ was removed on 09/20/15 at 4:11 p.m The Administrator and the DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 09/16/15, reflected the facility census was 88.

Based observation, interview and record review, the Administrator and DON failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being for one resident (Resident #6) of 18 residents reviewed for abuse/neglect. 1. The Administrator failed to implement the facility's Abuse Prevention and Prohibition Policy when she did not report Resident #6's bruising of unknown source to the State survey and certification agency and there was no evidence of a thorough investigation into the bruising. 2. The Administrator failed to supervise the DON to ensure she conducted a thorough investigation into Resident #6's bruising of unknown source. 3. LVN E, who was the charge nurse, and RN RR, who was the Weekend Supervisor, failed to follow the facility's Abuse Prevention and Prohibition Policy when they did not immediately report Resident #6's bruising of unknown source to the Administrator and DON. 4. ADON A failed to immediately report Resident #6's bruising of unknown source to the Administrator and DON. An Immediate Jeopardy (IJ) was identified on 09/18/15. While the IJ was removed on 09/20/15, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect all 88 residents by placing them at risk for mistreatment, abuse, and/or neglect by facility staff. Findings included: An electronic Event Report, created by LVN E on 09/12/15 at 4:16 p.m., reflected Resident #6 had a light purple bruise to her left eye measuring 2.0 cm x 4.0 cm on 09/12/15 at 3:15 p.m. An attached Investigation Report, completed by LVN E on 09/12/15, reflected Resident #6 had a bruise. LVN E documented, I asked resident (Resident #6) is she knew what happened. Stated No. The report was signed by ADON A and ADON B on 09/14/15. A typed statement, dated 09/15/15, from ADON A reflected she asked Resident #6 what happened to cause the bruise to the resident's left eye, and the resident was not able to verbalize what happened. An interview on 09/18/15 at 2:58 p.m. with the Administrator, who was the designated Abuse Prohibition Coordinator, revealed she would not have reported Resident #6's bruise to DADS. She explained she did not report the incident involving Resident #6 having a bruise to her left eye because she believed the bruise occurred when the resident was turned. The Administrator stated she knew the DON conducted an investigation including an interview with Resident #6, who responded positively when asked if the bruise occurred while she was being turned. The Administrator stated because of the interview, she believed the injury was not of unknown origin. She acknowledged the incident was not witnessed. When asked if a injury of unknown origin like a bruise was reported to her today would she report it to DADS, she stated she would not report it if they could come up with a possible explanation or cause of the injury. An interview on 09/19/15 at 1:20 p.m. with the Administrator revealed the factors contributing to the IJ situation were a system failure when RN RR did not follow the facility's policy and procedure for reporting incidents. She stated if the incident had been reported to the DON and Administrator, the approach and investigation would have been different. The Administrator stated all staff would receive in-service training regarding abuse/neglect. Also, the facility's system would be monitored at daily stand-up meetings to include going over any and all concerns with department heads to make sure they were being addressed. She stated any issues were taken to QA meetings. An interview on 09/18/15 at 11:50 a.m. with the DON revealed she was notified of the incident on 09/16/15, and she conducted her own investigation. She stated the incident involving Resident #6's facial bruise had not been reported to DADS. The DON was asked why the incident was not reported to DADS, and her response was that the resident's bruise was known. After reviewing Resident #6's care and routine, the DON stated she concluded the bruise must have happened when the resident was turned during care because of the closeness of her face to the side rail protector. She was asked if anyone witnessed that, and she said no. She stated she interviewed the resident, with the resident's family member present, if someone hurt her on purpose. The DON revealed Resident #6 answered uh uh, which she interpreted as no. She stated she then asked Resident #6 if the bruise on her eye happened when staff turned her during care, and the resident answered uh huh, which she interpreted as yes. During the interview, the DON provided a copy of DADS Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported (Replaces PL 06 -43) dated 08/19/14. She revealed since Resident #6 could give an account of how the bruise happened, it was a known injury and did not have to be reported within 24 hours. Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported (Replaces PL 06-43) dated 08/19/14 reflected under Reporting Abuse, Neglect, Exploitation and Other Incidents reflected the following: .8. SUSPICIOUS INJURIES OF UNKNOWN SOURCE (injuries of unknown source are defined in CMS Survey & Certification (S&C) 05-09). An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: · The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, · The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. An interview on 09/19/15 at 1:32 p.m. with the DON revealed the major failure was of RN RR to report the incident to the DON and Administrator. She stated there was a lack of communication between staff and administration. The DON stated in-services on abuse/neglect and dependent care were conducted with all staff on paydays. Regarding injuries of unknown origin, the DON stated all staff should report these to the supervisor, who should then begin an investigation. She stated incidents should also be reported to the DON and then to the Administrator. An interview on 09/18/15 at 3:45 p.m. with ADON A revealed RN RR was aware of Resident #6's bruise during the weekend of 09/12-09/13/15, but RN RR did not mention it to her. ADON A stated RN RR was working on the floor during the weekend, and this must have distracted her. ADON A was asked what the facility protocol for incidents involving unwitnessed or suspicious injuries. She stated staff should complete an incident report, notify the physician, family, the manager on duty, and the Administrator (Abuse Coordinator) right away, and the state should be called within 24 hours. An observation on 09/16/15 at 7:55 a.m. revealed Resident #6 lying in bed. The resident had a purple bruise under left eye measuring approximately 2.0 cm x 3.0 cm. The resident's hands and neck were contracted. LVN D, who was present during this observation, stated Resident #6's cognition was poor, and the resident was unable to speak, except to say uh huh (yes) and uh uh (no) when asked simple questions. LVN D stated Resident #6 required the assistance of two staff with dressing, bathing, toileting, and transfer by Hoyer lift daily to her wheelchair. She explained that the resident's left hand and neck were contracted, and the resident was incontinent of bowel and bladder, and she had contractures in her left hand and her neck. She added that the resident's skin was easily bruised. Resident #6's MDS assessment, dated 06/22/15, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with her ADLs to include bed mobility, transfer, and personal hygiene. The resident had functional limitation in range of motion to her bilateral upper and lower extremities. An interview on 09/18/15 at 3:15 p.m. with Resident #6, with the resident's family present, revealed the only intelligible or distinguishable answer was an uh huh (yes) when asked if the bruise occurred when she was in her chair. The resident did not answer intelligibly when asked if anyone had hurt her, if the injury occurred in her bed or chair, or if her face bruised when she was rolled into the side rail protector. Resident #6's family stated they thought the resident probably could not remember the incident now. A handwritten statement, dated 09/12/15, from CNA J reflected she assisted CNA L transfer Resident #6 using a Hoyer lift on 09/12/15 at 3:00 p.m. During that transfer, she documented, I noticed that she (Resident #6) had a small bruise under her left eye, after we transferred (sic) her. An interview on 09/18/15 at 11:16 a.m. with CNA J revealed she helped CNA L transfer Resident #6 with the Hoyer lift from bed to chair of Resident #6 on 09/12/15. CNA J stated she noticed the bruise under Resident #6's left eye, and she mentioned it to CNA L. She stated she did not know the cause of the bruise. A handwritten statement, dated 09/15/15, from CNA L reflected he provided care to Resident #6 on 09/12/15 with the assistance of CNA J and CNA U. CNA L documented, I never observed or noticed any bruise on the resident's (Resident #6) face till it was brought to my attention by the nurse in charge . An interview on 09/19/15 at 1:20 p.m. with CNA L revealed he worked with Resident #6 on 09/12/15 from 6:00 a.m. to 10:00 p.m. CNA L stated he turned the resident from side to side with assistance from CNA J when the resident's brief was changed and the resident was dressed. CNA L stated he did not notice a bruise on her face, and he stated the resident's face did not come close to the side rails during care. A typed statement, dated 09/14/15, from RN S reflected she assisted a CNA transfer Resident #6 on 09/12/15 around 6:45 p.m. when she noticed some purple discoloration on the resident's left eye. RN S asked Resident #6 what happened to her eye, and the resident shook her head and said she did not know. Resident Progress Notes, entered by LVN E on 09/12/15 at 3:15 p.m., reflected: Bruise light purple color below left eye observed. N/C (no complaints) of pain. (Family members) visiting with resident, up to W/C (wheelchair). Resident on Aspirin 81 mg daily. An interview on 09/18/15 at 11:26 a.m. with LVN E revealed she was the charge nurse for Resident #6 on 09/12/15, when the bruise to Resident #6's left eye was discovered. The report given to her from the 11:00 p.m. to 7:00 a.m. staff did not mention a bruise under Resident #6's eye. She stated Resident #6's family member came to her on 09/12/15 around 3:00 p.m. and reported that Resident #6 had a bruise under her left eye. LVN E stated she went to Resident #6's room and conducted a physical assessment, and she asked the resident if she was hurting. She stated the resident said uh uh which she interpreted as (no). She stated she asked the CNAs what had happened, and they all stated they did not know the cause of the bruise. She stated she then notified the Physician and the Weekend Supervisor, RN RR, of the bruise. LVN E stated she then charted the event in Resident #6's clinical record, and she began the investigation by interviewing staff. An interview on 09/18/15 at 3:55 p.m. with RN RR revealed she was aware of Resident #6's bruise the weekend of 09/12/15. She knew that an investigation was being done. She stated on 09/12/15 (Saturday) the bruise was not very dark, but it got darker on 09/13/15 (Sunday). She stated she did not mention the bruise to ADON A when she talked to her on the weekend of 09/12-09/13/15. RN RR stated she also did not notify the DON or Administrator about the bruise. She stated the protocol was to report a bruise of unknown injury to the DON and Abuse Coordinator (Administrator) as soon as it was discovered. RN RR stated on 09/14/15 (Monday) Resident #6's family member asked what had been discovered regarding the bruise, and ADON A read her the Event Report. Interviews on 09/18/15 at 11:26 a.m. with LVN E, RN RR at 3:55 p.m., ADON A at 3:45 p.m., the DON at 11:50 a.m., and the Administrator at 2:58 p.m. revealed there were no witnesses to the incident that caused the bruise to Resident #6's left eye. The facility's current, undated Abuse Prevention and Prohibition policy and procedure reflected the following: .IDENTIFICATION OF POSSIBLE INCIDENTS AND ALLEGATIONS 1. All employees are responsible for monitoring resident for possible signs of abuse. Methods of identification may include but are not limited to: .c. Reports made to the charge nurse or administrative staff member, residents, family members or visitors in regards to: .i. Unusual body marks in the resident .INVESTIGATION 1. The facility will always conduct an investigation of any allegation of abuse, neglect . 2. The investigation will be conducted according to State and Federal Guidelines by the Administrator, Director of Nursing, Abuse Prevention Coordinator and or other designee, and the .Police Department, if appropriate. a. The investigation will consist of, but not be limited to: .i. Resident assessment ii. Staff interviews iii. Family interviews iv. Roommate /hall mate interviews b. All interviews must be done in person, if possible. c. All steps of the investigation should be documented, including: i. Actions taken as a result of the investigation ii. Corrective actions taken to prevent the recurrence of the incident. d. The results of the investigation must be submitted to the Administrator. .REPORTING/RESPONSE 1. Staff must always report abuse immediately to the charge nurse and/or administration. .3. Incidents will be reported to the Texas Department of Human Services (DADS) in accordance with the guidelines contained in the current Provider Letter of the State Further review of the facility's Abuse Prevention and Prohibition policy and procedure revealed the policy did not address injuries of unknown source. An IJ was identified on 09/18/15. The Administrator, the DON, and the Medical Director were informed of the IJ on 09/18/15 at 4:29 p.m. A Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 09/20/15 at 4:11 p.m., reflected the following: .A skin assessment was completed on 9/18/2015 by ADON B, RN JJ and LVN UU. .Provider Investigation Report filed 5:30 p.m. on 9/18/2015 by the DON .Investigation of abuse was not substantiated and completed by ADON A on 9/15/2015 .A house wide audit of resident's skin status was completed by nurse managers on 9/18/2015 to identify suspicious bruising or other concerns of abuse. Skin Assessments completed by RN JJ, ADON B, LVN UU, RN S, LVN WW, LVN XX, RN YY. · Resident who are dependent and have a side rail were re-assessed for the device to ensure benefits are greater than risks (residents and responsible party will be involved in recommendations) - assessments were completed on 09/19/15 at 300 (p.m.). · All suspicious areas of unknown origin identified during the chart audits including event reports were reported within 24 hours to DADS according to (facility's) policy and procedure. Resident #1 totally dependent, skin tear right shin reported Resident #2 totally dependent, bruise right thigh Resident #3 totally dependent, bruise right thigh Resident #4 totally dependent, bruise right knee .Education was conducted by Senior Nurse Consultant. 9/18/2015 - Administrator and DON received education by RN Senior Nurse Consultant related to reporting responsibilities of all suspicious bruises, allegations of abuse upon notification (within 24 hours) followed by an investigation. Reporting to Department of Aging and Disabilities Services. Responsibility of educating staff at all levels and ensuring adherence to the Abuse Policies. Reporting to the Director of Management, Nurse Consultant, and Senior Nurse Consultant to ensure compliance with reporting policies and compliance to those policies. Nursing Supervisor (RN RR) was provided education by Senior Nurse Consultant (Senior RN Consultant) on 9/18/2015. DON conducted employee counseling on 9/19/2015. .Education was provided to nurse managers related to resident right to be free from abuse and also reporting responsibilities of health facility employees related to abuse and crime. Safety of resident/residents, removal of the perpetrator/perpetrators while conducting an investigation, and reporting the allegation of abuse to the Executive Director/abuse coordinator immediately. A verbal quiz was conducted with participants to validate understanding and competency. .Education was provided to employees (line staff /direct care givers - both licensed and non-licensed working on the evening and nights shifts on 9/18/2015 and day shift on 9/19/2015. Safety of resident/residents, removal of the perpetrator/ perpetrators while conducting an investigation, and reporting the allegation of abuse to the Executive Director /abuse coordinator immediately. A verbal quiz was conducted with participants to validate understanding and competency. · Daily rounds will be conducted by Nurse Managers and or nurse supervisor to ensure allegations of abuse and reporting responsibilities are understood by Licensed and non-licensed staff on-going. Questioning staff and interviewing and observing residents in a manor to support the safety of residents. · All employees will attend abuse training and have competency validated. · A notice posted at the time clock to remain in the break room upon clocking in for the shift - where education and competency validation will occur for all employees. · Employees working with direct resident care will receive education prior to reporting to the resident care area and must verbalize understanding of the responsibilities to identify and report abuse or allegations of abuse. · Supervisors will understand the responsibility to identify, report and then investigate abuse and or allegations of abuse following the policies and procedures. Education will be completed on all employees in each department prior to working a scheduled shift. Employees will not work until they have completed Abuse and Resident Rights and can verbally demonstrate competence of identification of abuse, when to report, resident safety and who to report to. .The Administrator has a 24 hour a day 7 days a week 365 days a year phone number posted at each nurses station and in the break room for employees. Completion date Sunday September 19, at 2400. An observation on 09/19/15 at 9:50 a.m. revealed the Senior RN Consultant providing an in-service to staff. Nine staff members were in attendance, and the in-service was interactive and required participation by staff members to verify understanding. In addition, staff members were given the facility's policy and procedure on abuse and neglect and copies appeared at the nurses' station and in common areas where employees congregated. Interviews were conducted on 09/20/15 from 10:45 a.m. through 3:30 p.m. with the following facility staff members, who represented staff from all three shifts: CNA Q, MA R, MA TT, RN S, RN JJ, LVN E, LVN GG, LVN LL, LVN D, Housekeeper T, CNA U, CNA V, Housekeeper W, CNA X, CNA Y, LVN Z, Cook AA, Dietary BB, Dietary CC, MA DD, Dietary EE, CNA MM, Dietary NN, RN RR, LVN OO, CNA ZZ, and CNA AAA. These interviews revealed staff members received in-service training on abuse, neglect and exploitation. The staff members were able to provide specific examples of suspicious injuries, such as bruising or discoloration on the face, neck or around the perineal area and upper thigh. The staff members were able to discuss what circumstances would require them to notify the charge nurse and the Administrator immediately. They identified any resident change in behavior such as change in personality, fear or guarding around a specific staff member, different behavior such as crying, refusing care or services as potential indications for possible abuse and neglect which would be reported to the Administrator. They were able to state that the Administrator was the facility's Abuse Prohibition Coordinator and how she could be reached. They were able to verbalize what needed to be reported and to whom they should make the report. The IJ was removed on 09/20/15 at 4:11 p.m The Administrator and the DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 09/16/15, reflected the facility census was 88.

Based on observation, interview and record review, the facility failed to ensure one (Resident #11) of three residents, who was fed by a [DEVICE], received the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities. LVN F and LVN G failed to assess Resident #11 for complications when she complained of pain during administration of medications and formula via her [DEVICE]. The failure could affect the four residents with [DEVICE]s by placing them at risk for abdominal pain/discomfort, diarrhea, and nausea/vomiting. Findings included: Resident #11's MDS assessment, dated 07/09/15, reflected she was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and was rarely/never understood by others or able to understand others. Resident #6 exhibited physical, verbal, and other behavioral symptoms between one to six days a week but less than daily. She required the extensive assistance of staff with her ADLs, was totally dependent upon staff for eating, and received her nutrition via tube feeding. Resident #11's Care Plan reflected a care plan, dated 07/06/15 and updated 07/19/15, addressing the resident's enteral feeding tube which was in place due to a [DIAGNOSES REDACTED]. An observation on 09/16/15 at 7:55 a.m. revealed Resident #11 lying in bed with her head elevated and her eyes closed. LVN G, who was present during the observation, stated Resident #11 had a [DEVICE] and received bolus feedings. An observation on 09/16/15 at 1:00 p.m. revealed Resident #11 lying in bed with her head elevated. LVN G checked placement of the resident's [DEVICE], and then administered a bolus feeding. Half way through the feeding, Resident #11 yelled out, Stop, please! Stop! It hurts! It hurts! LVN G asked the resident where it hurt, and she pointed to her stomach. LVN G continued administering the bolus feeding, and Resident #11 began to cry. LVN G was not observed to do a pain assessment during this time. An interview on 09/18/15 at 12:55 p.m. with LVN G revealed Resident #11 can be agitated during feedings. The nurses try to distract her and sometimes this works. Her reactions to the feedings seem to have increased in late August or early September 2015. When she first came, she took her feedings more easily. An observation on 09/17/15 at 8:00 a.m. revealed LVN F preparing to administer a feeding and medications to Resident #11. LVN F stated Resident #11 could be expected to cry during the procedure because it was one her behaviors related to dementia. LVN F first administered the feeding and then administered four crushed medications one at a time. From the beginning of the administration, Resident #11 told LVN F to stop and get away from her. She thumped him on the head with her finger, cursed, and slapped at him. LVN F continued the feeding, and the resident began to belch during the feeding and said she felt like throwing up. The resident was asked if she was hurting, and she began crying. She pointed to her upper abdominal area, and she stated, It hurts here. LVN F continued administering the formula, fluids and medications until they all were given. LVN F was not observed to do a pain assessment during this time. An interview on 09/18/15 at 12:50 p.m. with LVN F revealed he continued administering the resident's feedings despite the resident belching, crying, and complaining of nausea because she would lose weight if she did not receive the feeding. He stated an x-ray revealed Resident #11's [DEVICE] was in place. LVN F explained that he believed the resident's actions were part of her refusal of care and behaviors. He stated the resident fought any kind of care given to include incontinent care, baths, and dressing. An interview on 09/17/15 at 11:15 a.m. with the DON revealed she believed Resident #11's reaction to her feedings related to her dementia. She stated the resident never wanted the [DEVICE] and tried to pull it out. The DON stated the resident's physician was notified and placement was checked. An interview on 09/17/15 at 12:05 a.m. with the Nurse Practitioner revealed Resident #11 had been having nausea and belching for about three weeks. She stated the resident was recently started on [MEDICATION NAME] (an antiulcer drug), and it was still too early for this to have taken effect. She stated an x-ray was done to check for placement of the resident's [DEVICE]. The facility's current, undated Gastrostomy Feeding Tubes-Resident Care Guidelines reflected the following: POLICY: All residents with a feeding tube will be carefully monitored to: .2. Prevent complications PROCEDURE: .4. The resident should be observed closely for any adverse effects to the feeding procedure such as nausea, vomiting, diarrhea, gastric reflux or regurgitation, any signs of aspiration such as [MEDICAL CONDITION] dyspnea, coughing, wheezing, cyanosis, fever, rales, rhonci, etc. The following interventions are indicated in the event of an adverse reaction: a. Stop the feeding. b. Notify the physician for further instructions. c. Document the presenting symptoms on the nurse's notes. The Resident Census and Conditions of Resident Form CMS-672, signed and dated by the DON on 09/16/15, reflected four residents received tube feedings.