Every finding on record at Red Oak Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents and supervision.The facility failed to provide adequate supervision to prevent Resident #3, a resident with severe cognitive impairment, from exiting the facility through the front entrance during the night, and being located by local law enforcement in the roadway near a local business before being returned safely to the facility on 7/20/2026 at approximately 5:23 a.m.An Immediate Jeopardy (IJ) was identified on 08/18/2026. The IJ template was provided to the facility on [DATE] at 3:56 p.m. While the IJ was removed on 08/20/2026, the facility remained out of compliance at a scope of isolation and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of serious injury from elopement. Findings included:Record review of Resident #3's Quarterly MDS assessment, dated 05/09/2026, reflected the resident was a [AGE] year-old male admitted on [DATE] with diagnoses including vascular dementia (impaired memory), seizure disorder, Type II diabetes mellitus (elevated blood sugar), and muscle weakness. The assessment reflected a BIMS score of 0, indicating severe cognitive impairment. The resident was only sometimes understood, only sometimes understood others, exhibited inattention, and disorganized thinking, required a wheelchair for mobility, and required substantial to maximum assistance with activities of daily living. Record review reflected an Elopement Risk Assessment, completed on 07/06/2026, documented Resident #3 was not at risk for elopement/wandering at this time. Record review reflected an Elopement Risk Assessment, completed on 07/20/2026, documented Resident #3 was wandering the facility and attempting to exit the building. Record review of Resident #3's care plan, initiated 07/20/2026 and revised 07/21/2026, identified impaired safety awareness, exit-seeking behaviors, and the need to reside on a secure unit. In an interview on 7/22/26 at 2:30pm, Resident #3 stated he was doing well. Resident #3 was observed in his wheelchair roaming about the secure unit. He had no recollection of leaving the facility. During an interview on 07/22/2026 at 3:30 p.m., the Administrator stated he was unaware Resident #3 had eloped and believed the resident had never left the building. During an interview on 07/22/2026 at 3:53 p.m., the Social Worker stated she was aware only that Resident #3 demonstrated wandering behaviors and was transferred to the secure unit. She stated she had not been informed the resident left the facility or that law enforcement returned him. In an interview with local law enforcement on 07/22/2026 at 4:00 p.m., the responding officer stated he located Resident #3 at a local business in the roadway near the interstate on 07/20/2026 at approximately 5:23 a.m. after receiving a report of a traffic hazard. The officer stated he returned the resident to the facility and released him to nursing staff. During an interview on 07/22/2026 at 5:30 p.m., LVN A stated Resident #3 was provided a snack at around 4:00am on 07/20/26 and she believed he had returned to his room. LVN A stated approximately one hour later, local law enforcement returned the resident after locating him at a local business. LVN A stated she did a head-to-toe assessment and Resident #3 was not injured. She stated the Director of Nursing instructed her to complete an incident report, perform a comprehensive assessment, notify appropriate individuals, and initiate one-to-one supervision. She stated the Administrator later instructed her not to complete the incident report or document that the resident eloped and instead directed her to document only that the resident was wandering within the facility by completing an elopement risk assessment. LVN A stated she followed those directions because she feared losing her job. She further stated she assumed the resident exited through the front entrance because the front door did not lock from the inside during the night and could be opened by pushing on it. In an interview on 07/22/2026 at 6:00 p.m., the Director of Nursing stated she was notified of Resident #3's elopement from the facility on 07/20/2026 at approximately 5:45am. She stated she instructed LVN A to complete an incident report, perform a head-to-toe assessment, notify the physician and resident representative, and complete a new elopement risk assessment after learning Resident #3 eloped. She stated the Administrator was notified initially by her. The DON stated the Administrator called LVN A at the facility and instructed her not to document or report the elopement and instead directed her to chart only wandering behaviors within the facility. She stated her expectation was that the staff follow facility policy. During an interview on 8/06/26 at 1:00p.m., the AIT stated the receptionist was responsible for locking the front door at 10 pm. The AIT stated the door was not locked from the inside and anyone could walk up, push on the door from the inside and go outside. The AIT stated the receptionist stayed at the front of the building until 10:00pm every day. The AIT stated after 10:00pm it was the nursing staff's responsibility to make rounds and ensure residents did not exit the door at night. The AIT stated residents that were at high risk for wandering wore a wander guard on their person. The wander guard would lock the exit door if the resident attempted to open it and an alarm would sound to alert staff. The AIT stated Resident #3 did not have a wander guard because he had low risk for elopement prior to his actual elopement. Record review of facility policy titled, Elopements, dated 2001, reflected, Staff shall investigate and report all cases of missing residents. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: Examine the resident for injuries; Contact the Attending Physician and report findings and conditions of the resident; Notify the resident's legal representative (sponsor); Notify search teams that the resident has been located; Complete and file an incident report; Document relevant information in the resident's medical record.Record review of facility policy titled Wandering, Unsafe Resident dated 02/2012 reflected the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement.This was determined to be an Immediate Jeopardy (IJ) on 08/18/26 at 3:50 p.m. The DON and ADM were notified. The ADM was provided with the IJ template on 08/18/26 at 3:56 p.m. The following Plan of Removal submitted by the facility was accepted on 08/20/2026 at 11:30a.m.: Immediate Jeopardy (IJ) Removal Plan of Removal Date: August 18, 2026 Facility submits the following Plan of Removal for the alleged failure to provide adequatesupervision and implement appropriate interventions to prevent residents from leaving thefacility unsupervised. Immediate [NAME]:What corrective actions have been implemented for the identified resident? Resident #3 was immediately placed in a secured unit on 7/20/26 by LVN Charge Nurse, withsupervision appropriate to his current cognitive status, impaired safety awareness, wandering,and exit-seeking behaviors. A physical assessment was completed on 7/20/26 by LVN ChargeNurse and no injuries were noted.A comprehensive elopement risk assessment was completed on 7/20/26 by LVN Charge Nurse,and the resident's plan of care was reviewed and revised to reflect current wandering and exit seekingbehaviors on 7/20/26.The residents' physician and responsible party were notified of the elopement event andcurrent interventions on 7/20/26 by LVN Charge Nurse and Social Worker 12:21pm anddocumented in Resident #3 medical record.The DON/designee completed a review of residents residing outside of the secured unit toidentify residents with any potential risk for elopement by completing a new Elopement RiskAssessment on each resident. None were identified. This was started on 7/22/26 andcompleted on 7/23/26. Additionally, elopement risk assessments initiated and completed againon 8/18/26 by DON. Any resident identified with potential elopement risk received animmediate reassessment, care-plan review, and implementation of individualized supervisionand safety interventions, 1 resident required a care plan update on 7/20/26 and 1 residentrequired a care plan update on 8/18/26.All exterior exit doors were immediately inspected by the Administrator/MaintenanceDirector/designee to ensure that doors, locking mechanisms, alarms, and resident-safetysystems were functioning as intended. They were also inspected on 7/30/26 by Corporate PlantOperations. The wander guard system was tested on [DATE] by ADON to ensure properfunction. Maintenance Director is checking wander guard alarm for proper function daily.Until permanent verification of the locking/alarm system was completed, designated staff wereassigned to continuously monitor any exit that could not be confirmed as secure. Dedicatedstaff will remain at the front door 24/7 until mag lock is in place and functioning, mag lock will be placed as soon as approved by Fire Marshall, tentatively scheduled for 8/21/26 and will have code pad upon installation. Mag lock will have 15 second delay when door handle is held down. Until installed doors will remain on 24/7 surveillance.How were other residents at risk to be affected by this deficient practice identified?Residents that are at risk of elopement have the potential to be affected by the alleged deficientpractice.What does the facility need to change immediately to keep residents safe and ensure it doesnot happen again?A. An in-service was initiated on 7/22/26 by the Clinical Service Director, DON, and NurseManagers with the licensed nursing sta on the Elopement Policy and wandering behaviors. ClinicalServices Director completed training with DON and Nurse managers on 7/22/26 prior to DON and nursemanagers educating sta . Licensed nurses will not be allowed to return to work until they receivethis in-service. Completion date 7/23/26. Additionally, this was again initiated on 8/18/26 withposttest validation. Sta were educated on what behaviors constitute wandering, and how to respond tothose behaviors, who to notify-charge nurse, ADON/DON, physician and responsible party, and whatactions to take post assessment and noti cations.B. An in-service was initiated on 7/22/26 by the Nurse Managers with the facility frontline sta on the procedure to follow when it is deemed there is a missing resident. Completion date 7/23/26. Additionally, this was again initiated on 8/18/26 with posttest validation. C. Newly hired nurses will be in-serviced by the DON/designee on the Elopement Policy and wandering behaviors. Licensed nurses will not be allowed to work until they receive this in-service. D. Newly hired frontline sta will be in-serviced by the DON/designee on the Elopement Policy and wandering behaviors. They will not be allowed to work until they receive this in-service. E. New Admissions and Readmissions and residents experiencing a change in condition related to wandering/exit seeking behaviors will have an Elopement Assessment and Risk Management completed and will be reviewed daily in the morning meeting by the DON/Designees to identify residents at risk for elopement and ensure adequate supervision is in place.Quality Assurance:An impromptu Quality Assurance and Performance Improvement review of the plan of removal wascompleted on 8/18/26 with the Medical Director. The Medical Director has reviewed andagrees with this plan.Monitoring the POR on 8/18/26 included the following:In an observation on 8/18/26 4:00p.m. to 4:58p.m. Nine residents requiring wander guards were assessed for placement and evaluated to ensure proper functioning of alarm. One wander guard bracelet was identified as not functioning as the alarm did not sound at exit and was replaced immediately by the facility on 8/18/26 at 4:58pm, retested, and sounded the alarm.Monitoring the POR on 8/19/26Record review of Resident #3s' Progress notes effective date 7/20/26 6:45 and created date 7/22/26 8:17p.m. reflected Upon the resident's return, a comprehensive nursing assessment was performed immediately. The resident was awake and responsive. Mental status and orientation remained at the resident's baseline with no noted change from prior assessment. The resident denied pain or discomfort. No signs of acute distress were observed. Skin assessment revealed no new abrasions, lacerations, bruising, swelling, or other visible injuries. The resident was able to move all extremities at baseline, with no apparent deformities or complaints noted. Respirations were even and unlabored, and no obvious signs of trauma were identified. The Director of Nursing (DON) was notified immediately of the elopement and the resident's safe return. The DON notified the Administrator. The Administrator stated, Do not Worry I will notify (RP) and the attending physician of the incident The resident was placed on 1:1 observation with a CNA to ensure safety and prevent further elopement attempts. The resident remained calm following return to the facility, with no further wandering or exit-seeking behaviors noted, at this time. Signed by LVN ARecord review of door audit dated 7/21/26 reflected that all exterior exit doors were immediately inspected by the Administrator/Maintenance Director Designee to ensure that doors, locking mechanisms, alarms, resident -safety systems were functioning as intended. They were also inspected on 07/30/2026 by Corporate Plant Operations.In an observation on 08/19/26 at 08:00a.m. staff were sitting at a desk near the front door. The staff were monitoring the front door to ensure residents did not leave facility from the front entrance.Record review of Elopement Risk Assessments dated 7/22/26. 7/23/26, and 8/18/26 reflected they had been completed on all residents.Record Review of the policy Inservice titled Wondering and Elopement dated 07/22/26 reflected staff must report a suspected missing resident to the charge Nurse. A search of the facility and grounds must be completed. If not, found the administrator, DON, Responsible Party, and Physician, 911 must be contacted immediately. This in-service was given electronically and all staff acknowledged they read and received the in-service. The entire policy was reviewed. Record review of the in-service reflected all staff had acknowledged they had received this in-service of elopement policy and protocol. This was initiated on 07/22/2026 and completed on 07/23/26. All staff acknowledged they had received the Inservice as evidenced by them marking on the system they acknowledged they had received Inservice.Record Review of staff posttest of Inservice titled Wandering and Elopement reflected 24 of 80 staff completed the post test. Initiated on 08/18/2026 and it is ongoing when new staff come on duty they are taking the post test. Record Review of Inservice Education reflected in person in-service on what behaviors constitutes wandering, how to respond to those residents who exit seek, new behaviors of wandering, who to notify and what actions to take post assessment and notifications. Initiated on 08/18/2026 and is ongoing and it is also on the post test.Record review of AD HOC QAPI meeting reflected it was held on 08/18/2026 and attended by the following: DON, ADON, Regional Nurse, Regional Director of Operations, Medical Director, Social Worker, Dietary Manager, Activity Director, Rehab Director.In interviews on 08/19/2026 from 8:00am to 10:00a.m. with CNA U, MA T, LVN R, CNA Q, LVN P, LVN O, LVN N, RN M, CNA L stated they had been in serviced on the elopement protocol. They stated they monitor residents by making rounds q 2 hours and as needed. Staff would notify the supervisor if a resident were pacing or seeking to exit the facility. They stated if an elopement were to occur the staff were responsible for searching the entire premises and surrounding areas of the building. They would activate Code Green, indicating there was a missing resident. Immediately notify The ADM and DON and call 911. They stated if a resident were to begin to wander and exit seek the DON should be notified. They stated if a resident were to leave the facility and elope, an incident report should be completed including all facts within the nurses' notes, notify the physician and family of exactly what had happened. They stated new assessments would be completed, and the care plan would be updated with new interventions.Monitoring the POR on 8/20/26In an observation on 8/20/26 at 3:35p.m. the exterior front door and exterior door to 300 hall had a maglock installed, operable and locked.In interviews on 08/20/2026 from 2:45p.m. and 4:48p.m. with CNA V, CNA X, LVN Y, CNA Z, LVN AA, CNA BB, CNA CC, CNA DD, LVN EE, all who work the night shift, stated they had been in serviced on the elopement protocol. They stated they monitor residents by making rounds q 2 hours and as needed. Staff would notify the supervisor if a resident were pacing or seeking to exit the facility. They stated if an elopement were to occur the staff were responsible for searching the entire premises and surrounding areas of the building. They would activate Code Green, indicating there was a missing resident. Immediately notify The ADM and DON and call 911. They stated if a resident were to begin to wander and exit seek the DON should be notified. They stated if a resident were to leave the facility and elope, an incident report should be completed including all facts within the nurses' notes, notify the physician and family of exactly what had happened. They stated new assessments would be completed and the care plan would be updated with new interventions.In an interview on 08/20/26 at 4:23pm The DON stated he reviewed all residents for elopement risk and found none on 7/22/26-7/23/26. He was in-serviced by corporate nurse on elopement and ANE. He then in-serviced ADON and licensed nurses on ANE and elopement. He taught staff that residents who exhibit aimlessly wandering or seeking out an exit constituted wandering behaviors. He taught staff to redirect and notify charge nurses, ADON and DON. He also taught staff to have charge nurse reassess and reevaluate for risk of elopement. He also taught staff to perform head count, check all residents' rooms and common areas and outside premises, notifying police, ADM, family, and physician, perform head-to-toe assessments and skin assessments on residents, and notify all parties. QAPI met on 8/18/26. MD was present via phone, and a performance improvement plan was developed from the QAPI. Post-test evaluations were given to staff on elopement and ANE prior to working shift. Maglocks installed and all exterior checked and operable and secured.The ADM was informed the Immediate Jeopardy was removed on 08/20/26 at 5:42 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 3 of 5 residents (Resident #1, Resident #2, and Resident #3) reviewed for neglect.1. The facility failed to implement its Abuse and Neglect-Clinical Protocol by not investigating and reporting to local and state authorities to local an altercation between Resident #1 and Resident #2 on 06/12/2026.2. The facility failed to implement its Abuse and Neglect Protocol by not investigating and reporting to local and state authorities after Resident #3 eloped from the facility on 07/20/2026.These failures could place residents at risk of no timely investigation, physician involvement, resident representative notification, appropriate monitoring, and interventions designed to protect residents from further abuse, neglect, exploitation, or harm.Findings included:Record review of facility policy titled, Abuse and Neglect-Clinical Protocol, dated 2007, reflected, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with the support of the physicians (as needed), will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. The physician will order measures required to address the consequences of an abuse situation, such as psychological evaluation or suturing of a laceration. The physician and staff will address causes of problematic resident behavior where possible, such as mania (a paranoid state), psychosis (mental confusion), and medication side effects. The staff and physician will monitor individuals who have been abused at least until their medical condition, mood, and function have stabilized, and periodically thereafter. The Medical Director will advise facility management and staff about systems to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. The Medical Director will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum:Protocols for conducting employment background checks;Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactionsIdentification of occurrences and patterns of potential mistreatment/abuse;The protection of residents during abuse investigations;The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident-to-resident abuse and resident-to-staff abuse;Timely and thorough investigations of all reports and allegations of abuse;The reporting and filing of accurate documents related to incidents of abuse;An ongoing review and analysis of abuse incidents; and the implementation of changes to prevent future occurrences of abuse.Resident #1 / Resident #2Record review of Resident #1's Annual MDS assessment, dated 03/01/2026, reflected Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that make breathing difficult), urinary tract infection, muscle weakness, and unspecified dementia (impaired memory and thinking). The assessment reflected a BIMS score of 1, indicating severe cognitive impairment.Record review of Resident #1's care plan, dated 07/01/2025 and updated 08/15/2026, reflected a behavior problem related to Wernick's encephalopathy (a brain disorder causing confusion) as evidenced by urinating in closet, dresser drawers, and on the side of the wall. He also was care planned for demonstrating ineffective coping and physical aggression. Interventions included to give clear, concise explanation of anything about to occur; avoid information overload since the angry aggressive resident cannot assimilate many details.Record review of late entry nursing documentation, dated 06/12/2026 at 11:45p.m. authored by RN E, reflected, This nurse was called to the resident's room by the CNA, who reported observing the two roommates on the floor facing each other. Upon entering the room, this nurse observed [Resident #1], sitting in the chair. No physical contact was observed. [Resident #2] was sitting on the bed and the nurse observed blood on the floor which was coming from [Resident #1's] left ring finger. Assessment revealed a wound to the left fourth finger with active bleeding. The wound bed was cleansed, and pressure was applied until bleeding was controlled. A skin tear to the left fifth finger was also noted, cleansed, and covered with dry dressing. No other injuries were observed during the assessment. Vital signs were obtained. Resident complained of pain, and Tylenol 325 mg, two tablets by mouth, was administered as ordered. Notifications were made to family member, Administrator, ADONs, and Doctor. After receiving assessment findings, Doctor instructed that the resident be sent to the hospital for further evaluation. Resident was transferred to Hospital for assessment and treatment. Condition at time of transfer was stable.Record review of Treatment Administration Record for June 2026, July 2026, and August 2026, reflected Resident #1 required wound care for left hand 4th finger including a treatment of cleanse area with wound cleanser, pat dry, apply xeroform a Vaseline gauze, and cover w/ gauze, and wrap every day and as needed until healed daily starting June 13, 2026. The wound was healed on August 8, 2026.Observation and interview on 07/24/2026 at 09:00 a.m. revealed Resident #1 was clean and dressed appropriately for the weather. He stated he was looking for his family member and was confused. He was able to show his left-hand 4th finger that had a brown crusted scab across the tip. The area was not red and not draining. He had no recollection of what happened to his finger and stated it felt fine. Resident #1 denied any pain.Record review of Resident #2's Quarterly MDS assessment, dated 04/28/2026, reflected Resident #2 was a [AGE] year-old male admitted on [DATE] with diagnoses including dementia (impaired memory), cerebral infarction (a stroke), anxiety disorder, and diabetes mellitus (elevated blood sugars). The assessment reflected a BIMS score of 3, indicating severe cognitive impairment, and documented behavioral symptoms.Record review of Resident #2's care plan, dated 09/30/2025, reflected inappropriate behaviors related to spitting on staff and family, and verbal aggression towards staff and other residents at times. Interventions included redirect resident from situations when he becomes agitated and showed verbal aggression.Record review of Resident #2's Psychiatric Subsequent Assessment, dated 06/14/2026, reflected Patient is seen for evaluation of current psychiatric medications. Staff reports no side effects. ADON reported that on 6/12/2026, this resident was involved in an altercation with his roommate, but he is okay. A gradual dose reduction was scheduled on resident's medication but was cancelled due to resident's recent behavior.Record review of facility census for Resident #2 reflected he was discharged to another facility on 06/16/2026.The facility was unable to provide an investigation for the abuse allegation between Resident #1 and Resident #2 on 6/12/2026.Record review of TULIP on 7/22/26 reflected no incidents of abuse or elopement had been reported involving Resident #1, Resident #2 or Resident #3.In an interview on 8/6/26 at 3:06 pm with RN E, she stated that the nurse aides heard a commotion in the room on 06/12/2026 at 11:45p.m. When she arrived Resident #1 was sitting in a chair, he had blood coming from his left-hand 4th finger and Resident #2 was sitting on his bed. She stated she did not witness the incident. She stated she assessed Resident #1 and applied a dressing to his finger, notified the doctor of the wound and was provided an order to send him to the hospital. She stated Resident #2 was moved to another room away from Resident #1 that night. She stated she notified the administrator of a resident-to-resident altercation, the ADON and both families. She stated she completed an incident report. She stated both residents have a history of behaviors so she could not definitively say which resident was the aggressor. She stated Resident #1 required daily wound treatment, and his finger has been healing. She stated Resident #2 was discharged from the facility within the same week. RN E stated she did not see and neither did any other staff see Resident #2 bite the tip of Resident #1's finger off. She stated it was unclear what exactly happened to Resident #1's finger during the incident. She stated at the time of the incident there was an assumption that Resident #2 bit Resident #1's finger but no one witnessed it and the residents were unable to report what happened. An interview with the CNA that found Resident #1 and Resident #2 was attempted on 08/06/26 at 12:00 and the CNA did not return requests for an interview. Resident #3Record review of Resident #3's Quarterly MDS assessment, dated 05/09/2026, reflected the resident had severe cognitive impairment with a BIMS score of 0, impaired safety awareness, disorganized thinking, wheelchair dependence, and required substantial to maximum assistance with activities of daily living.Record review reflected an Elopement Risk Assessment, completed on 07/06/2026, documented Resident #3 was not at risk for elopement/wandering at this time.Record review reflected an Elopement Risk Assessment, completed 07/20/2026, documented wandering behaviors and attempts to exit the facility.Record review of Resident #3's care plan, initiated 07/20/2026 and revised 07/21/2026, identified impaired safety awareness, exit-seeking behaviors, and the need to reside on a secure unit.Record review of Resident #3s' Progress notes effective date 7/20/26 6:45 and created date 7/22/26 8:17p.m. reflected Upon the resident's return, a comprehensive nursing assessment was performed immediately. The resident was awake and responsive. Mental status and orientation remained at the resident's baseline with no noted change from prior assessment. The resident denied pain or discomfort. No signs of acute distress were observed. Skin assessment revealed no new abrasions, lacerations, bruising, swelling, or other visible injuries. The resident was able to move all extremities at baseline, with no apparent deformities or complaints noted. Respirations were even and unlabored, and no obvious signs of trauma were identified. The Director of Nursing (DON) was notified immediately of the elopement and the resident's safe return. The DON notified the Administrator. The Administrator stated, Do not Worry I will notify (RP) and the attending physician of the incident The resident was placed on 1:1 observation with a CNA to ensure safety and prevent further elopement attempts. The resident remained calm following return to the facility, with no further wandering or exit-seeking behaviors noted, at this time. Signed by LVN ADuring an interview on 07/22/2026 at 3:30 p.m., the Administrator stated he was unaware Resident #3 eloped and believed the resident had never left the building.In an interview with local law enforcement on 07/22/2026 at 4:00 p.m., the responding officer stated he located Resident #3 at a local business in the roadway near the interstate on 07/20/2026 at approximately 5:23 a.m. after receiving a report of a traffic hazard. The officer stated he returned the resident to the facility and released him to nursing staff.In an interview on 07/22/2026 at 5:30 p.m., LVN A stated Resident #3 was provided with a snack at around 4:00 am on 07/20/26 and believed he had returned to his room. Approximately one hour later, local law enforcement returned the resident after locating him at a local business. LVN A stated she did a head-to-toe assessment and Resident #3 was not injured. She stated the Director of Nursing instructed her to complete an incident report, perform a comprehensive assessment, notify appropriate individuals, and initiate one-to-one supervision. She stated the Administrator later instructed her not to complete the incident report or document that the resident had eloped and instead directed her to document only that the resident had been wandering within the facility by completing an elopement risk assessment. LVN A stated she followed those directions because she feared losing her job. She further stated she assumed the resident exited through the front entrance because the front door did not lock from the inside during the night and could be opened by pushing on it.In an interview on 07/22/2026 at 6:00 p.m., the Director of Nursing stated she was notified of Resident #3's elopement from the facility on 07/20/2026 at approximately 5:45am. The DON stated she instructed LVN A to complete an incident report, perform a head-to-toe assessment, notify the physician and resident representative, and complete a new elopement risk assessment after learning Resident #3 had eloped. She stated the Administrator was notified initially by her. The DON stated the Administrator called LVN A at the facility and instructed her not to document or report the elopement and instead directed her to chart only wandering behaviors within the facility. She stated her expectation was that the staff follow facility policy and from her nursing experience, she would have reported this incident to the state, reported it to the family and the physician implemented new interventions with a care plan as well as completed the incident report. The ADM, DON, and [NAME] President were unable to provide an investigation for the elopement when requested on 07/21/26 upon entry, and again on 07/22/26 at 3:00pm of Resident #3 on 07/20/2026.During a telephone interview on 08/06/2026 at 2:30 p.m., the Regional [NAME] President stated all allegations of abuse and neglect should be investigated and reported. The Administrator was responsible for initiating and ensuring a full investigation was completed including reporting. The Regional [NAME] President stated staff should have been interviewed and statements should have been obtained He stated it was important to follow policy to ensure these types of incidents did not recur. He stated if the policy was not followed it would place residents at risk for abuse and neglect.Record review of facility policy titled, Elopements, dated 2001, reflected, Staff shall investigate and report all cases of missing residents.Record review of facility policy titled Reporting Abuse to Facility Management dated 2009 reflected It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. To help with recognition of incidents of abuse, the following definitions of abuse are provided: Injury of unknown source is defined as an injury that meets both of the following conditions:(1) 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(2) 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.Record review of facility policy titled, Abuse Investigations, dated 2009, reflected, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents received services with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 15 residents (Residents #19 and #20) reviewed for call light accessibility.The facility failed to ensure the call light system was accessible to Residents #19 and #20 on 07/22/26 at 10:45 a.m.This failure could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury or pain.Findings included:Record review of Resident #19's Face Sheet, dated 07/22/26, reflected that Resident #19 was a [AGE] year-old male admitted on [DATE] with diagnoses of atrial flutter (fast or pounding heartbeat), mood disorder (low mood or loss of pleasure in activities), major depressive disorder (persistent sadness, loss of interest in activities, and low energy), dementia (a loss of memory, thinking, and reasoning skills), benign prostatic hyperplasia without lower urinary tract symptoms (an enlarged prostate gland that causes no noticeable urination changes or discomfort), heart failure (heart muscle does not pump blood effectively), hypertension (high blood pressure), muscle weakness, dysphasia (difficulty talking, writing, or understanding what other people are saying), other lack of coordination (brain, nerves, and muscles are not working together smoothly), cognitive communication deficit (trouble with thinking and processing skills), protein calorie malnutrition (body does not get enough food, calories, or protein to stay healthy), and generalized anxiety disorder (excessive worry, constant tension, and feeling restless).Record review of Resident #19's BIMS score, dated 02/16/2026, revealed a score of 5, indicating severe cognitive impairment.Record review of Resident #20's Face Sheet, revealed that Resident #20 was a [AGE] year-old male admitted on [DATE] with diagnoses of Hepatic encephalopathy (damaged liver cannot remove toxins from the body), chronic kidney disease stage four kidneys cannot remove waste, toxins, and extra fluid effectively), generalized osteoarthritis (joint disease leading to pain, stiffness, and reduced mobility), abnormalities of gait and mobility, anemia (not enough healthy red blood cells to carry oxygen around the body), type two diabetes mellitus without complication (has not yet developed any diabetes-related damage to organs or tissues), hyperlipidemia (having too much fat, like cholesterol and triglyceride in the blood), hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery without angina pectoris (heart arteries have plaque buildup, narrowing them, but not having chest pain from it), gastroesophageal reflux disease without esophagitis (acid reflux symptoms without visible inflammation of the esophagus), cirrhosis of the liver (scarring of the liver caused by various diseases and conditions), muscle weakness, benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate which involves non-cancerous growth of the prostate gland), cognitive communication deficit, and dependence on renal dialysis.Record review of Resident #20's BIMS score, dated 05/23/2025, revealed a score of 12, indicating moderate cognitive impairment.In an interview and observation on 07/22/2026 at 10:40 a.m., Resident #19 was in his wheelchair in his room and watching television. Resident #19 had difficulty speaking, and Resident #19's voice was not clear. Observation revealed the call light button was not within reach of the resident and on the other side of the bed. Resident #19 stated he did not know how to get the call light and someone needed to give the call light to him. LVN J arrived in the room after being called by the surveyor. LVN J stated Resident #19 always stayed on this side of the bed which was next to the restroom. LVN J stated she would place the call light button near Resident #19. LVN J placed the call light button to the side of the bed within Resident #19's reach In an interview and observation on 07/22/2026 at 10:45 a.m., Resident #20 was in his wheelchair watching television in his room. Resident #20 stated he just got here last night. Resident #20 stated staff members were treating him okay. Observation revealed Resident #20's call light button was not within reach, and when asked, How are you going to call the nurses if you need help? Resident #20 stated if you hand me the call light button, then I can call them. The surveyor went to the nursing station and got the nurse, then I went the resident's room, retrieved the call light from the bedside stand, handed it to Resident #20, and asked Resident #20 if he needed anything else. Resident #20 said he did not need anything else at this time.In an interview on 07/22/2026 at 3:31 p.m., LVN I stated that she saw Resident #20 in his wheelchair, watching television, and that his call light button was not reachable. LVN I stated she obtained the call light button and put it within reach. LVN I stated the call light button was between the nightstand and the bed, and on the floor. LVN I stated that a call light button not being within reach was not acceptable, but it may have fallen during the transfer to the wheelchair. LVN I stated staff were educated to ensure call light buttons were within reach for all residents. LVN I stated that a negative outcome of the call light button not being within reach is that the residents would not be able to use the call light to ask for help or to verbalize the need for help. LVN I stated some prevention measures included frequent rounds to ensure the call light was within reach, and staff were reminded of its importance in in-services.In an interview on 07/22/2026 at 2:55 p.m., LVN J stated Resident #19 was always in his wheelchair next to the wall and his bed. LVN J stated that having the call light button on the other side of his bed, out of reach, was not appropriate. LVN J stated that a negative outcome of the call light button not being within reach would be that Resident #19 could fall and not be able to ask for help. LVN J stated that one prevention measure was to educate CNAs to ensure call light buttons were reachable so residents could use them when needed. LVN J stated that she was in-serviced on call lights.In an interview on 07/22/2026 at 4:15 p.m., CNA K stated she was in serviced on a regular basis for call lights. CNA K stated that the only way to get a hold of the staff was by using the call light button, and if the call light button was not within reach, that would not be appropriate. CNA K stated one negative outcome of the call light button not being reached was falls and yelling. CNA K stated she checked the call light button each time she went to any resident's room.In an interview on 07/24/2026 at 2:08 p.m., the DON stated the call light should always be within reach. The DON stated if call light buttons were not within reach, residents would be at risk of falls and delayed care. The DON stated she instructed staff members about the call light to ensure call lights buttons were within reach of residents. The DON stated walking rounds frequently, being proactive, and checking on residents were some ways to make sure call light buttons were within reach of residents.Record review of facility policy titled, Answering the Call Light, revised in March 2012 stated under General Guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interviews and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change of condition for 1 of 6 (Resident #1) residents reviewed for comprehensive assessments.The facility did not complete a significant change MDS for Resident #1 after he was transferred to another hospice services on 06/04/2026.This failure could place residents at risk of not having their individual needs met when a significant change in condition occurs.Findings included:Review of Resident #1's face sheet, dated 06/26/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included malignant (likely to worsen or spread) neoplasm (abnormal and uncontrolled growth of tissue) of lower lobe (bottom sections of lung) left bronchus (airway passage) or lung, hypertension (high blood pressure), and chronic obstructive pulmonary disease (lung disease that restricts airflow and makes breathing difficult).Review of Resident #1's care plan dated 06/15/2026 revealed he was admitted to hospice services for diagnoses of senile degeneration of the brain (progressive deterioration of brain tissue and function that occurs beyond what is considered normal aging).Review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 09, indicated moderate cognitive impairment with hospice care while at the facility.Review of Resident #1's clinical physician's order dated 06/04/2026 revealed he was admitted to another hospice company due to a malignant (likely to worsen or spread) neoplasm (abnormal and uncontrolled growth of tissue) of lower lobe (bottom sections of lung) left bronchus (airway passage) or lung.Review of Resident #1's MDS assessments in the EHR revealed no significant change assessment was conducted after Resident #1 had switched to another hospice service company on 06/04/2026. There was no significant change assessment completed by the MDS Coordinator by 06/17/2026.In an interview on 06/26/2026 at 2:42 PM with the MDS Coordinator, she stated she was responsible for completing the significant change assessment by 06/17/2026 when Resident #1 switched to another hospice services company on 06/04/2026. The MDS Coordinator stated she did not know how she missed the significant change assessment when Resident #1 switched hospices services. The MDS Coordinator stated it was expected for her to complete the significant change with fourteen days of Resident #1 changing hospice services. The MDS Coordinator stated it was very important to make sure the MDS reflected Resident #1's significant change. The MDS Coordinator stated when changes are not updated in the MDS it could cause the facility not to receive payments and the residents would not receive their services.In an interview on 06/26/2026 at 3:55 PM with the DON, she stated it was expected for the MDS Coordinator to have updated the MDS with significant change within 14 days of Resident #1 switching hospice services. The DON stated when the MDS was not updated funds would be taken back from the State and residents would not get the proper care that was provided to them.In an interview on 06/26/2026 at 5:00 PM with the ADM, he stated it was expected for the MDS Coordinator to have completed the significant change MDS within 14 days of hospice company change. The ADM stated the MDS assessments were expected to be completed timely for Resident #1. The ADM stated it was important for the significant change assessment to be completed to make sure that the residents' needs were provided for.Review of the facility's policy named Minimum Data Set (MDS) Submission Timeframes dated 2001 revised December 2006 reflected, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to the state MDS database in accordance with current federal and state guidelines.Review of the facility's policy named Resident Assessment Instrument dated 2001 revised December 2009 reflected, A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission.The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule:Within fourteen (14) days of the resident's admission to the facility;When there has been a significant change in the residents' condition;At least quarterly: andOnce every twelve (12) months.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for dietary services.The facility failed to ensure food was safely stored, labeled, and dated in the walk-in refrigerator on 03/11/2026.The facility failed to ensure food was safely stored, labeled, and dated in the kitchen pantry on 03/11/2026.These failures have the potential to affect the residents who ate food from the facility's kitchen, placing them at risk of foodborne illness. Findings include:Observation of the kitchen pantry on 03/11/2026 at 9:28 AM revealed:1.One plastic bag with a box of quick creamy wheat. There was no 'open date or 'use by date' documented.2. One gallon of BBQ sauce with an open date of 03/02/2026. There was no 'use by date documented.3. One opened gallon of apple cider vinegar with an 'open date' of 09/15/2025. There was no 'use by date' documented.4. One opened gallon of soy sauce with a date of 10/09 and an open date of 11/03/2026. There was not a 'use by date' documented.5. One opened plastic jar of peanut butter with an open date of 02/27/2026. There was no 'use by date documented.6. One opened gallon of liquid smoke that did not have an 'open date' or 'use by date' documented.7. One gallon of molasses unsulphured original that had an open date of 12/01/2025. There was no 'use by date' documented.8. One plastic bag of chips with a date of 03/02/2026 and did not have a 'use by date' documented.9. One plastic bag of wafer cookies with an open date of 02/10/2026 and did not have a 'use by date' documented.10. One plastic container with graham crackers that did not have an 'open date' or a 'use by date' documented.11. One plastic container with saltine crackers that had an open date of 02/09/2026. There was no 'use by date' documented.12. One opened package of elbow macaroni that was covered with plastic wrap and did not have an 'open date or 'use by date' documented.13. One opened package of spaghetti noodles that was covered with plastic wrap and had an 'open date' of 01/26. There was no 'use by date' documented.14. One opened plastic bottle of dill weed that had a received date of 08/07/2025. There was not an 'open date' or 'use by date documented.15. One opened package of brown gravy mix that was covered with plastic wrap and had an 'open date' of 03/02/2026. There was no 'use by date documented.16. One opened plastic bag of yellow cake mix that had an 'open date' of 03/05/2026. There was no 'use by date documented.17. One opened plastic bag of chocolate cake mix that had an 'open date' of 03/05/2026. There was no 'use by date documented.During an interview with the PC on 03/11/2026 at 9:36 AM, she stated that once food was opened, there should be an 'open date' and a 'use by date' documented on each container. She stated that not properly dating and labelling the food would put residents at risk of food-borne illnesses.Observation on 03/11/2026 at 9:40 AM revealed a sign (undated) posted on the walk-in refrigerator that reflected the following in capital letters: EVERYTHING MUST BE LABELED AND DATED BEFORE IT HITS THE COOLER/FREEZER!!! ALL COOKED ITEMS MUST BE discharged WITHIN 48 HOURS!!! NO EXCEPTIONS!!!!Observation on 03/11/2026 at 9:44 AM of the walk-in refrigerator in the kitchen revealed the following:1. One opened plastic bag of garlic bread that had an 'open date' of 03/09/2026. There was no 'Use by date documented.2. One opened plastic container of apples that had an 'open date' of 03/09/2026. There was no 'Use by date documented.3. One opened carton of thickened lemon-flavored water that had an 'open date' of 03/02/2026. There was no 'use by date' documented.4.One opened plastic container of peaches that had an 'open date' of 03/10/2026. There was no 'use by date' documented.5. One opened metal pan of ham that had an 'open date' of 03/04/2026. There was no 'use by' date documented.6. One metal pan of lettuce and tomatoes that had an 'open date' of 03/06/2026. There was no 'use by date' documented.7. One opened plastic bag of potato wedges that had an 'open date' of 03/03/2026. There was no 'Use by date documented.8. One opened plastic bag of hash browns that had an 'open date' of 03/05/2026. There was no 'use by date' documented.9.One opened plastic container of strawberries with a red gel-like substance on the side of container. There was not an 'open date' or 'use by date' listed on the container.During an interview on 03/11/2026 with the PC at 9:52 AM, she stated food items that were placed in the refrigerator should have an 'open date' and a 'use by date' (the used by date was 48 hours from the open date). The PC advised that not having these dates listed could place residents at risk of foodborne illnesses.During an interview on 03/13/2026 at 1:57 PM with the RPM, she stated food items that were stored in the pantry should be dated when received. The RPM said the container should have an 'open date' and a 'use by date' once it was opened. The RPM stated that refrigerated items should be dated when opened and the used date was 48 hours from the 'open date'. The RPM advised that not safely storing and dating food items could place residents at risk of food borne illnesses.Record review revealed there was an in-service that covered the topic Label-N-Dating on 02/25/26 facilitated by the PC. Record review revealed the following undated policies were reviewed and reflected the following: Food receiving Policy and Procedure - Policy statement: This policy establishes guidelines for the safe handling of all food items during transport, delivery, and storage, with a focus on maintaining strict time and temperature controls to ensure food safety.5. Labeling and Dating: All food items must be clearly labeled and dated, using either the manufacturer's packaging information or manual staff entries, to ensure traceability and freshness Dry Goods Storage Policy and Procedures - Policy statement: This policy ensures that all dry goods are stored in compliance with the FDA Food Code standards to maintain their quality and safety.6. Organization: Storage area shall be organized and maintained in a manner that allows for easy identification and access to items, with all good appropriately date labeled.During an interview on 03/13/2026 at 2:20PM with the ADM, he stated he did not know that staff did not properly date all food items properly. He stated an in-service was completed in February 2026 regarding dating and labeling food in the kitchen. He advised that not properly dating and labeling food in the kitchen could put residents at risk of foodborne illnesses. He concluded that this would be monitored more closely.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 6 residents (Resident #111) reviewed for medications storage. During medications administration, MA A left Resident #111 without ensuring medications were swallowed. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of medications.The findings included: Record review of Resident #111's face sheet, dated 03/13/26, reflected an admission date of 06/16/23, with diagnoses which included: cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain), hypertension (high blood pressure), atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), and dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities). Record review of Resident #111's Quarterly MDS dated [DATE] reflected Resident #111's had a BIM's score of 05 which indicated she was severely cognitively impaired. Review of MDS reflected Resident #111 required supervision or touching assistance with eating and toileting, substantial/maximal assistance with showers, and partial or moderate assistance with personal hygiene. MDS reflected Resident #111 was diagnosed with hypertension. Record review of Resident #111's physician's orders dated 11/20/25 reflected an order for Lisinopril Oral Tablet 20 MG (Lisinopril) Give 1 tablet by mouth one time a day for HTN hold for SBP less than 100 or DBP less than 60. The physician's order's reflected Resident #111 did not have an order for Aspirin. Record review of Resident #111's MAR dated 11/20/25 reflected Lisinopril Oral Tablet 20 MG (Lisinopril) Give 1 tablet by mouth one time a day for HTN hold for SBP less than 100 or DBP less than 60 -Start Date11/20/2025 0600. Resident #111's MAR reflected medication was given on 03/11/26 and Resident #111's BP was 126/63. Review of Resident #111's care plan, dated 01/26/26, revealed a focus of Resident #111 had the potential for s/sx and complication r/t hypertension, a goal of Will remain free from s/sx of hypertension, and interventions that included give anti-hypertensive meds as ordered. Observe for side effects such as orthostatic hypotension (an increase in blood pressure with standing typically in relation to kidney diseases), and increased heart rate. In an interview and observation on 03/11/26 at 12:11 PM, revealed Resident #111 had a round light orange pill beside her arm in her bed. She stated she did not know what the pill was or who gave it to her. She stated she did not feel like being bothered. Resident #111 moved the pill from her bed to her bedside table. She stated she did not know whose pill that was or if someone brought it to her. Resident #111 appeared pleasantly confused and stated the surveyor had the wrong person because she was not getting any surgery today. The Surveyor explained to the resident they were not at the facility for her to have surgery. Resident #111 turned her back toward the surveyor. In an interview on 03/11/26 at 12:20 PM, MA A stated she thought that the medication found on Resident #111's bedside was an aspirin and she believed Resident #111 took that medication every morning. She stated she had given Resident #111 her medication that morning and she watched the resident take and swallow the medication. She stated she was trained on watching and ensuring residents took their medications and that they swallowed the medications before she left the room. She stated if a resident had a medication left lying on the bed or they had not swallowed their medication, another resident could have come in and taken the medication or the resident that did not take the medication could have gotten a headache or not have the desired effect from the medication. In an interview on 03/12/26 at 4:03 PM, MA A stated on the previous day when she was asked about the medication found on the resident's bed that she thought was aspirin, she went back and looked at the resident's MAR and found that resident did not take aspirin. She stated she found that the medication was Lisinopril (medication given to lower blood pressure) and she went and told her nurse. She stated her nurse came back and told her to go ahead and give the medication and she went and gave the resident her medication. She stated she checked the resident's blood pressure and pulse prior to giving resident the medication and everything was in parameters to give the medication. She stated that was about 12:40 PM when she gave the medication and there were no adverse reactions or effects from the medication being given late. In an interview on 03/13/26 at 9:45 AM with the ADON, she stated MA A came to her yesterday and she could not remember exactly what time, but MA A told her there was a medication that was found by the surveyor in Resident #111's bed. She stated MA A thought that the medication was an aspirin but they went and looked at Resident #111's MAR to find out what the medication was. She stated they found that the medication was a Lisinopril 20 mg tab. She stated the MD was in the facility at that time and she informed the MD about the medication being found in Resident # 111's bed. She stated the MD told them to give Resident #111 the medication. She stated she and MA A disposed of the medication that was found and MA A went and checked Resident #111's BP, prepared the medication, and administered the medication. She stated nurses and medication aides were trained on staying with residents when medications were administered and ensuring residents swallowed their pills. She stated if a medication was not taken correctly and remained out in the open such as on a residents bed, another resident or roommate could have taken the medication and the resident that did not swallow them medication properly could have had an increased blood pressure. In an interview on 03/13/26 at 1:17 PM, the DON stated the nurses and medication aides were responsible for administering medications to the residents. She stated when medications were administered to the residents the staff who administered the medication should have stayed with the resident until all of the medications were swallowed. She stated the nurses and medication aides had been trained on medication administration and ensuring residents had swallowed their medications before they left the residents room. She stated if medications were left out in the open or on a resident's bed, another resident could have taken the medication. She stated the resident could have missed a very important medication or a resident's blood pressure could have risen. In an interview on 03/13/26 at 1:21 PM, the ADM stated the licensed nurses and medication aides were responsible for administering medications to the residents. He stated it was his expectation that when medications were administered to the residents, the staff who administered the medication should have stayed with the resident until all of the medications were swallowed. He stated the nurses and medication aides had been trained on medication administration and ensuring the resident had swallowed their medications before they left the residents room. He stated if medications were left out in the open or on a resident's bed, another resident could have taken the medication or in this case, it could have caused a spike in blood pressure. Record review of the facility's policy titled, Storage of Medication, dated April 2007, reflected Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for one (1) of one (1) facility kitchen and one (1) of two (2) nourishment rooms reviewed for food safety (Station 2 Med Room). 1. The facility failed to ensure food items in the kitchen refrigerator were dated and labeled. 2. The facility failed to ensure the ice machine in the kitchen and in one (1) of two (2) nourishment rooms were cleaned and free of mold, mildew and slime. 3. The facility failed to discard a dented can. 4. The facility failed to discard food items past their expiration date. 5. The facility failed to maintain accurate freezer temperature logs for the freezer in the kitchen and one (1) of two (2) freezers in the nourishment rooms (Station 2 Med Room). 6. The facility failed to keep food properly sealed and covered in the refrigerator. 7. The facility failed to provide a thermometer for the measurement of the freezer temperature in one (1) of two (2) freezers in the nourishment rooms (Station 2 Med Room). 8. The facility failed to ensure staff were familiar with, trained, and able to operate kitchen equipment in accordance to safety regulations. These failures could place residents at risk for food-borne illness and cross contamination. Findings include: Observation of the dry goods storage area within the kitchen on [DATE], at 9:09AM revealed one of five 6.56 lb cans of pears in light syrup to were dented and damaged. In a follow up trip to the kitchen, DDM was advised of the dented and damaged can and instructed to remove it from use. He obliged but offered no explanation as to why the product remained in the storage area. Observation of the kitchen refrigerator on [DATE], at 9:12 AM revealed cups of liquids or soft food items were missing a label which indicated a thawed date and a use by date. Five of these cups of liquids or soft food items were missing a label identifying the substance in each of the cups. Observation of the kitchen refrigerator on [DATE], at 9:13 AM revealed five 3lb containers of ricotta cheese were not discarded after their expiration or use by date of [DATE]. One (1) of the five (5) containers of ricotta cheese was open and used, with a prep date of ,d+[DATE] listed on the label only. Following this observation, DDM was notified of the expired items and instructed to dispose of the items. Upon re-inspection, these items were no longer in the refrigerator. The DDM offered no explanation as to why the products remained in the refrigerator. Observation of the kitchen refrigerator on [DATE], at 9:13 AM revealed five (5) of five (5) 3lb containers of ricotta cheese were not properly labeled and dated with date of receipt or a use by date. Four unopened containers of ricotta cheese were stored in a box with [DATE] written in black marker on the outside of the box, with no indication as to the significance of this date. Observation of the kitchen refrigerator on [DATE], at 9:17 AM revealed five stacks of sliced American Cheese, of various counts (not individually wrapped), which were opened and wrapped in plastic wrap without an open or preparation date or use by date label on the products. One of the stacks of American Cheese had ,d+[DATE] written on the plastic wrap, with no indication as to the significance of this date. Observation of the kitchen refrigerator on [DATE], at 9:17 AM revealed three containers of prepared food, lacking proper labels identifying the item contained within, preparation dates, and/or use by dates. One container had a partially completed label which stated, Item: Baked beans. Prep date: ,d+[DATE], but contained no use by date. Observation of the kitchen refrigerator on [DATE], at 9:19 AM revealed a prepared pan of brown gravy covered by plastic wrap that did not fully cover the pan or seal the contents within. Observation of the kitchen freezer on [DATE], at 9:20 AM revealed a pumpkin pie with the label on the item showed the name of the item, the date it was prepared, ,d+[DATE], but lacked a use by date. Observation of the kitchen ice machine on [DATE], at 9:22 AM revealed the presence of black, grey, white, and pink patches with a slimy or fuzzy texture indicative of mold, mildew, and slime build-up on the interior under guard and drum of the machine. A follow up observation of the kitchen ice machine was conducted on [DATE], at 10:01 AM. The presence of mold, mildew and slime build-up remained on the interior guard and drum of the machine. Observation of the freezer temperature log on [DATE], at 10:09 AM revealed staff logged a temperature of 0 in advance for the morning of [DATE]. Observation of one (1) of two (2) nourishment rooms (Med room [ROOM NUMBER]) on [DATE], at 10:25 AM, revealed a prepackaged, store bought, frozen meal in the freezer with a resident's first and last name written on the box in ballpoint pen. There were no dates and no room number on the box. The nourishment rooms were for the storage of resident items only. Observation of a sign posted in nourishment room [ROOM NUMBER] on [DATE], at 10:25AM, read in part: Please Put Name, Room #, and Date on All Items!! .Nurse Management. Observation of the freezer compartment of the refrigerator in nourishment room [ROOM NUMBER] on [DATE], at 10:26AM, revealed no working thermometer inside and no freezer temperatures logged for the month of [DATE]. Observation of the ice machine in nourishment room [ROOM NUMBER] on [DATE], at 10:27AM, revealed the presence of black, grey, white, and/or pink patches with a slimy or fuzzy texture indicative of mold, mildew, and/or slime build-up on the interior under guard and drum of the machine. In an interview with DS D on [DATE], at 10:11 AM, while running the kitchen dishwasher, DS #4 stated he did not know the appropriate temperature parameters of the dishwasher or how to test for the correct chemical solution concentration level. DS D stated this was his first time running the dishwasher. DS D stated that he usually cooked or prepared food, but never washed dishes. DS D stated he was instructed to run the dishwasher by the DDM. While interviewing DS D, the DDM interjected and briefly explained to DS D how to check the temperature and disinfectant concentration level using the high temperature thermometer and chemical test strips. Interview with the DDM on [DATE], at 11:39 AM, revealed the DDM was responsible for all auditing of food items in the dry goods storage area/pantry, refrigerators and freezers. The DDM said he was currently the account holder for the facility, so he ordered all facility dietary goods, hired, and trained staff, and ensured policy and procedures were followed. The DDM stated their procedure for food storage and labeling consisted of the dietary aides putting up delivered food products in their proper place (putting up the truck) and labeling all food items received with their delivery date and open date. In an interview with the MNT on [DATE], at 3:20 PM, the MNT stated he had been employed with the facility for 2 years. He stated the facility contracted with his employer to provide dietary and maintenance services to the facility. The MNT stated that he checked equipment daily to ensure it was in proper working condition. The MNT stated he didn't always get the things he needed to properly do his job, such as support or resources, but he managed. The MNT stated this does did not cause a hardship for the residents as he would use alternatives means if necessary to ensure the facility and equipment were in working order. The MNT stated he was responsible for the maintenance and cleaning of the facility's ice machines. He stated he believed he cleaned the ice machines quarterly, but he does not maintain a cleaning and service log for this equipment. The MNT stated the last time the ice machines were cleaned was when the former DM was employed. The MNT confirmed the former DM left his position in about [DATE]. In an interview with the DON and the ADON collectively on [DATE], at 4:56 PM, both stated it was their expectation that the company that oversaw dietary and maintenance services would ensure their staff were properly trained and certified. Each stated that a possible result of dietary staff in particular not being properly certified is that residents could become ill or this could cause food to become contaminated if staff were unaware of proper food handling techniques. In an interview with the ADM on [DATE], at approximately 5:00 PM, the ADM stated it is was his expectation that the company they contracted with for dietary services would maintain the highest level of service and knowledge, including current certifications and training. The ADM stated that a lack of such could lead to residents become ill. Record review of the facility's dietary policies indicated: Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Record review of the facility's policies and procedures revealed the following information in part: Work Order/Maintenance Policy and Procedures indicates that it is the responsibility of the department directors, charge nurse and/or certified staff to fill out and forward work orders to the Maintenance Director. This would include work orders for thermometers or ice machines. Food Storage: Cold Foods Policy and Procedures indicates that an accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. All foods will be wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Receiving (of food items) Policy and Procedures indicates that all canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. Ice Policy and Procedures indicates ice will be prepared and distributed in a safe manner .The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines . Equipment (food service) Policy and Procedures indicates that all food service equipment will be clean, sanitary, and in proper working order. All staff members will be properly trained in the cleaning and maintenance of all equipment.

Based on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for five (5) staff reviewed for qualified dietary staff. The facility failed to ensure that dietary DS B, DS D, DS E, DS G, and DS H obtained and/or maintained their Texas Food Handler Certificates. This failure practice could place residents who ate from the facility's only kitchen at risk of foodborne illness and not having their nutritional needs met and at risk of contracting foodborne illnesses. Finding Include: Record review of the dietary staff personnel files completed on January 15, 2025, at 2:41 PM, revealed the following: DM's hire date to be 12/9/2024. DS F's hire date to be 11/28/2023. DS G's hire date to be 12/20/2024. DS H's hire date to be 7/10/24. Texas Food Manager Safety Certification for DDM with an expiration date of 5 years from the effective date of 7/5/2023. Food Allergens Essential Course certificate of completion for DDM issued on 9/23/2024 and valid 2 years from the issuance. Record review of additional dietary staff personnel records provided by the DDM on January 15, 2025, at 3:41 PM revealed the following: Texas Food Handler certificate for DS D issued on 1/13/2025. Staff schedules for the last 90 days which show that DS D worked 72 shifts between 10/1/2024-1/12/2025 without a confirmed or verified valid food handler certificate. Texas Food Handler certificate for DS E issued on 1/13/2025. Staff schedules for the last 90 days which show that DS E worked 19 shifts between 10/1/2024-1/12/2025 without a confirmed or verified valid food handler certificate. Texas Food Handler certificate for DS G issued on 1/13/2025. Staff schedules for the last 90 days which show that DS G worked eight (8) shifts from 12/20/2024-1/12/2025. Texas Food Handler certificate for DS H issued on 1/13/2025. Staff schedules for the last 90 days which show that DS G worked 70 shifts between 10/1/12024-1/12/2025 without a confirmed or verified valid food handler certificate. In an interview with the DDM on January 15, 2025, that began at approximately 3:45 PM, attempts were made to clarify staff, their roles and titles, and documents and records provided by the DDM for the dietary staff. The DDM explained that the this facility contracted with his employer for dietary and maintenance services. The DDM stated his title was District Manager in training. The DDM stated his manager was the RDM. The RDM was the Regional Manager in training. The current Dietary Manager in training was the DM, who would also be the facility's account manager. Per the DDM, all responsibility for the kitchen and dietary staff was the responsibility of the DDM until the DM was fully trained. The DDM was unfamiliar with all the staff members listed on the schedule and did not provide a complete roster of dietary personnel. The DDM provided conflicting information when answering questions regarding personnel and their qualifications. The DDM stated that the former DM had his own system of scheduling and keeping up with personnel records that the DDM was not entirely familiar with and could not fully explain. The DDM could not provide food handler certificates for staff as requested. The DDM stated initially that he was unsure as to why groups of dietary staff had the same recertification dates. The DDM then said that the dietary staff recertified on the same dates, but on separate computers within the office. The DDM denied the certificates were obtained fraudulently. The DDM admitted he did not have all the past and current food handler certificates as requested. The DDM stated he could not locate records maintained by the prior DM. The DDM stated he has been overseeing the facility's dietary services for the last couple of months since the former DM of 5-6 years resigned. The DDM stated the former DM handled all management duties, but he was now discovering a lapse in that management. The DDM stated all dietary staff confirmed to the DDM their Food Handler Certificates were current, and he accepted their confirmation as factual. In an interview with the DON and ADON collectively on January 15, 2025, at 4:56 PM, both stated that it was their expectation that the company who oversaw dietary and maintenance services would ensure their staff were properly trained and certified. Each stated a possible result of dietary staff in particular not being properly certified was that residents could become ill or this could cause food to become contaminated if staff were unaware of proper food handling techniques. In an interview with the ADM on January 15, 2025, at approximately 5:00 PM, the ADM stated it was his expectation the company they contracted with for dietary services maintained the highest level of service and knowledge, which included current certifications and training. The ADM stated a lack of such could lead to residents become ill. Record review of job descriptions for [NAME] and Dietary Aide show one qualification for both positions to be, Current ServSafe or Food Handler certification is required . Record review of the 2022 United States Food and Drug Administration Food Code, Section 2-103 entitled Duties, states in part: 2-103.11 PERSON IN CHARGE. The person in charge shall ensure that: (O) EMPLOYEES are properly trained in FOOD SAFETY .

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 medication storage rooms (room located by hall 400) and 2 of 2 medication carts (Hall 400 Medication Aide's Cart and Hall 400 Nurse's Cart). 1. The facility failed to ensure expired medication administration supplies and Covid test were removed from 1 of 2 medication storage rooms (room located by hall 400). 2. The facility failed to follow policy and date opened medications on 2 of 2 medication carts (Hall 400 Medication Aide's Cart and Hall 400 Nurse's Cart). These failures could place residents at risk for ineffective treatments, incorrect diagnosis, cause a Peripheral IV Catheter to need replacement and or allow Covid infections to spread. Findings include: Observation on [DATE] at 12:23 PM of the 400 hall Medication Aide's Cart revealed the following medications were opened, but no date showed when they were opened: 1 Bottle of Geri Care-One daily Multivitamin-100 tabs 1 Bottle of Thiamine Vitamin B-1 100mg-100 tabs 1 Bottle of Magnesium Oxide 400mg-120 tabs 1 Bottle of Geri Care-Ferrous Sulfate 325 Mg Vitamins-100 tabs 1 Bottle of Melatonin 1 Mg-60 tabs 1 Bottle of Melatonin 5 Mg-90 tabs 1 Bottle of Vitamin C 500mg-100 tabs Observation on [DATE] at 1:34 PM of the Medication Storage Room located by the 400 hall revealed the following: 30 Covid-19 Ag Card test Covid test expired on [DATE]. 30 Extension Set Product 8 Expires 12 31 2024 01 Extension Set with Care site Luer-Access Device Expires [DATE] Observation on [DATE] at 1:46 PM of the 400 hall Nurse's Medication Cart revealed the following medications were opened, but no date showed when they were opened: Omeprazole 20mg 14 caps Allergy Relief 100 tablets (Diphenhydramine HCL 25mg) In an interview on [DATE] at 12:23 PM with MA-A, she stated the policy for opening new medication bottles was to date them when opened. She stated she knew better than to leave them undated and she would date them now. She said if medications were undated, they could become poisonous and cause residents to become sick or nauseous. In an interview on [DATE] at 1:34 PM, LVN-A stated the policy on expired medical supplies was to discard them in the bin. She stated the nurses were responsible for checking the medication rooms and dating opened medications. LVN-A stated expired items could lose their potency and the residents would not get the full potential of their medications. In an interview on [DATE] at 2:44 PM with the DON, she stated the policy on expired medical supplies was to remove them and it was the responsibility of the Assistant Director of Nurses to oversee it. The DON stated in the future she would oversee the medication rooms also. The DON stated the negative outcome to residents if expired items were used, was they could lose effectiveness and residents could get sick. The DON stated the policy on opening new medications was to date the bottles and it was the responsibility of the nurses and the nurse managers. She said it was important to date medicines when they were opened so you would know how long they had been on the cart. The DON stated the negative outcome to residents if medications were not dated would be the medicine could potentially lose effectiveness. In an interview on [DATE] at 2:50 PM with ADM, he stated the policy on expired medical supplies was to remove them from the medication room. He stated it was the responsibility of the Charge Nurses and the DON to check the medication room. The ADM stated expired items could lose effectiveness and cause health issues for residents. The ADM stated the policy was to date medications when they were opened, and it was the responsibility of the Charge Nurses and the DON to check the carts. He stated it was important to date medications, so you knew when to dispose of them. The ADM stated the negative outcome to residents if medications were not dated was the medications could lose their effectiveness. Record review of the facility's policy labeled Administering Medications, dated 2001 Med-Pass, Inc., (Revised 2012) reflected, When opening a multi-dose container, the date opened shall be recorded on the container. Record review of the facility's policy labeled Storage of Medications, dated 2001 Med-Pass, Inc., (Revised 2007) reflected: The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review 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 1 of 6 residents (Resident #36) reviewed for infection control. CNA A failed to wash or sanitize her hands while going from a dirty to clean surface while performing incontinent care on 01/14/25 at 1:30 PM for Resident #36. This deficient practice could place residents at risk for cross contamination and the spread of infection. Findings include: Record review of Resident #36's care plan, dated 11/13/24, reflected: Resident #36 was incontinent of bowel and bladder. Goal: Risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI. To be clean, dry and odor free. Interventions: Check for incontinence during rounds; wash, rinse, dry perineum, and change clothing PRN after incontinence episodes. Observe/report to MD any s/sx of UTI: pain, burning, blood-tinged urine, increased frequency, fever, foul smelling urine, AMS. Record review of Resident #36's face sheet, dated 01/14/25, reflected a [AGE] year-old female with an admitted [DATE]. Resident #36 had diagnoses which included hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), diabetes (a group of diseases that result in too much sugar in the blood), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and respiratory failure (results from inadequate gas exchange by the respiratory system meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels). Record review of Resident #36's quarterly MDS assessment, dated 01/09/25, reflected Resident #36 had a BIMS score of 15, which indicated Resident #36 was cognitively intact. Resident #36 required supervision or touching assist with eating, and required substantial or maximal assist with bathing, toileting, and personal hygiene. Resident #36 was always incontinent of bowel and bladder. In an observation on 01/14/25 at 01:30 PM, CNA A performed incontinent care with assistance of IP for Resident #36. CNA A and IP washed their hands and applied their gloves. IP stood on Resident #36's right side and CNA A stood on Resident #36's left side. CNA A informed Resident #36 what she was going to do and removed the sheet which was covering Resident #36. CNA A unfastened Resident #36's brief and began incontinent care. When incontinent care was completed on the front, CNA A and IP turned Resident #36 on her right-side facing IP, and CNA A continued to perform incontinent care. CNA A removed her gloves, then applied new gloves and continued to perform incontinent care. CNA A had not washed or sanitized her hands in between glove change. CNA A placed Resident #36's clean brief under the dirty brief and removed the dirty brief from under Resident #36. CNA A placed the clean brief in the appropriate place on Resident #36 and fastened the brief. CNA A and IP removed their gloves and washed their hands . In an interview on 01/14/25 at 1:47 PM, the IP stated she saw CNA A perform the incontinent care on Resident #36 because she had assisted CNA A in positioning the resident. She stated she saw CNA A change her gloves multiple times but to be honest, she did not know the exact time CNA A had changed her gloves. She stated staff were supposed to change their gloves when they went from a dirty to a clean surface and they should have sanitized their hands in between the glove change. She stated she was in-serviced on infection control, handwashing, and peri-care. She stated if gloves were not changed and hands had not been sanitized when going from a dirty to clean surface, it could cause the spread of infection or a UTI. In an interview on 01/14/25 at 1:58 PM, CNA A stated she recently performed incontinent care for Resident #36. She stated after completing the incontinent care on the front and beginning incontinent care on Resident #36's backside, she removed her gloves and sanitized her hands. She stated she applied clean gloves and continued to clean Resident #36's backside and then she replaced the dirty brief by putting a clean brief under the dirty brief first, and then removed the dirty brief. She stated she usually changed her gloves after going from a dirty surface to a clean surface and she was just nervous because the State Surveyor was watching her. She stated she was in-serviced on infection control, handwashing, and incontinent care, and she knew she should have changed her gloves and sanitized her hands when going from a dirty to clean surface. She stated if staff had not changed their gloves or sanitized their hands when going from a dirty to clean surface, it could have caused infections for the residents. In an interview on 01/15/25 at 11:32 AM, the DON stated it was her expectation that staff changed their gloves and sanitized their hands in between gloved changes when going from a dirty to clean surface. She stated staff were trained often on infection control, incontinent care, and hand washing. She stated if staff had not changed their gloves or sanitized their hands in between the glove change, it could have caused the risk for infection, especially if they had feces on their gloves. In an interview on 01/15/25 at 11:43 AM, the ADM stated it was his expectation staff changed their gloves and sanitized their hands in between gloved changes when going from a dirty to clean surface, and staff were supposed to do this. He stated staff were trained often on infection control, incontinent care, and hand washing. He stated if staff had not changed their gloves or sanitized their hands in between the glove change, it could have caused a resident to get a UTI, sepsis, or an infection could have occurred. Record review of the facility's in-service titled In-Service Training Attendance Record and dated 10/01/24 with a subject of Gloves are NEVER to be worn in the hallways under no circumstances. Gloves are to be changed in between use and in between resident(s). Perform hand hygiene after doffing and donning gloves. reflected staff, inclcanng CNA A which had signed the document, had been trained on hand hygiene being performed after donning and doffing gloves. Instructor of in-service was the IP. Record review of the facility's in-service titled In-Service Training Attendance Record and dated 11/11/24 with a subject of Monitors - The following monitors must be completed during rounding and throughout the day. If you observe any of the following, make corrections immediately and notify the manager in charge. Hand Hygiene. reflected staff, including CNA A which had signed the document, had been trained on hand hygiene. Record review of the facility's Perineal Care policy, dated 2001 and revised December 2011, reflected the following: .2. Wash and dry your hands thoroughly. 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place. 18. Remove gloves and 19. Wash and dry your hands thoroughly

Based on observation, interviews, and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team including both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #20) reviewed for care plans. The facility failed to ensure Resident #20's comprehensive care plan was revised to reflect the need for and the use of a fall mat. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest practical well-being. Finding include: Record review of Resident #20's Face Sheet revealed an eighty-two (82) year old female who was, admitted to the facility on [DATE]. Her diagnoses included essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus with unspecified conditions (a chronic condition characterized by insulin resistance and elevated blood sugar levels), hyperlipidemia (high cholesterol), unspecified dementia (a decline in cognitive function), Alzheimer's Disease (a disease which commonly causes dementia), and muscle weakness. The resident's advance directive was full code/CPR. Record review of Resident #20's admission MDS Comprehensive Assessment revealed the assessment was completed on [DATE]. According to the assessment, Resident #20's BIMS was one, which indicated severely impaired cognition. Resident #20 had impaired vision, functional limitation in her range of motion with impairment in one side of her lower extremity, with no mobility devices used. Resident #20's functional abilities, which included sit to stand, chair/bed-to-chair transfer, walking ten (10) feet, walking 50 feet with 2 turns, and walking 150 feet was dependent on a helper or helpers to complete these activities. The MDS assessment did not address the resident's risk for falls. Record review of Resident #20's Comprehensive Care Plan last reviewed by the facility on [DATE], revealed Resident #20 also had a diagnosis of Unspecified Fracture of Shaft of Left Femur, Subsequent Encounter with Routine Healing. The comprehensive care plan did not to list a fall-injury prevention program as a focus area, with no goals or interventions listed, including the need for a fall mat. Record review of Resident #20's physician's orders revealed no physician's order(s) for any type of assistive device to prevent falls or injury from falls or the need for a fall-injury prevention program. Record review on of the facility's MDS Resident Matrix (a tool used to identify pertinent care categories for residents) completed by the ADM revealed that Resident #20 had no specific care areas marked, including fall, fall with injury, or fall with major injury. Observation of Resident #20 on [DATE]. 2025, at 10:49AM revealed the resident in bed, resting with her eyes open. The resident was slightly alert but did not verbally respond to questions asked of her. Resident #20 was observed to be in a single occupancy room, with her bed positioned against the wall on its left side. On the floor to the right of Resident #20's bed was a fall mat. (Fall mats are specially designed floor mats used to protect from serious physical trauma resulting from falls.) Observation of a photograph on the cell phone of Resident #20's RR on [DATE], at approximately 10:55AM, showed how Resident #20's RR found Resident #20 on [DATE]. The photograph depicted the resident in the condition as described below, torso laying across the bed, legs dangling off the side. In an interview on [DATE], at 10:49AM, Resident #20's RR stated that the resident was admitted to the facility after hip replacement surgery on [DATE]. Resident #20's RR stated on [DATE], at 8:00 AM, he arrived to the facility and found the resident lying sideways in her bed, her torso on the bed, and both legs dangling off of the side of the bed, as if she had been attempting to get out of bed and slid. The RR alerted staff and they assisted the resident back in bed properly. On or about [DATE], staff placed a thick fall mat next to the resident's bed as a safety measure. Resident #20's RR stated initially staff placed a very thick fall mat next to the resident's bed, but later replaced the thick mat with a thinner mat due to the thicker mat being seen as a hazard concerns. In an interview on [DATE] at 3:47 PM, the DON stated the MDS was responsible for completing the initial care plans and also for revising the care plans as needed. She stated she also updated care plans at times herself. She stated the MDS was trained on completing the care plans accurately. She stated it was her expectation that fall mats would be included in a resident's care plan. She stated she was not aware Resident #20 had fall mats or that the fall mats were not care planned. She stated she was going to find out about the fall mats and if Resident #20 was supposed to have them. She stated if fall mats were not included in a resident's care plan, it could lead to a resident falling and hurting themselves. In an interview on [DATE] at 3:56 PM, the MDS stated she was responsible for completing and updating the residents' care plans. She stated that she has beenwas trained on completing the care plans accurately. She stated she was aware Resident #20 had fall mats because she helped place the fall mats in Resident #20's room. She stated the fall mats were placed due to the family request and she did not realize that she had not care planned them until informed by the State Survey team. The MDS stated she was going to care plan the fall mats now that she had been informed this information was missing. The MDS stated she would normally care plan fall mats as an intervention when fall mats were placed. She stated if fall mats were not care planned, the staff may not be aware a resident needed fall mats, which could cause the mats not to be used to aide in a fall or injury or it could have caused a safety hazard and staff could have tripped over the fall mats if they had not known they were there. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised [DATE], reflected in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Assessments of residents is ongoing and care plans are revised as information about the residents' conditions change. Record review of the facility's policy and procedures, Falls, Clinical Protocol, revised [DATE], reflected in part: 5. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events

Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 8 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure MA A secured Resident 1's medication when she left Resident #1's medications on her bedside table for her to self-administer and did not ensure the resident took her medication. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: Record review of Resident #1's face sheet reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (Stroke a disruption of the blood flow to the brain causing part of the brain to die), dehydration, post-traumatic stress syndrome, unspecified psychosis, and anxiety disorder. Record review of Resident #1's care plan dated 10/17/2023 reflected she was resistive to care related to episodes of refusing medication. Her goal was for her to cooperate with taking medications as per medical doctors orders through next review date. Interventions were If Resident #1 resist taking medications leave and return 5-10 minutes later and try again. If Resident #1 continues to refuse to take medications notify medical doctor and responsible party and document in chart. Record review of Resident #1's Quarterly MDS assessment, dated 10/24/2024, reflected she had a BIMS score of 15, which indicated she was cognitively intact. Resident #1 was coded Substantial Maximal Assistance with her ADLs (dressing, bathing, grooming, and toileting) indicating the helper or staff performed more than half the effort for the resident to complete the task . In an interview and observation on 11/20/24 at 10:30 AM Resident #1 stated she had no concerns with abuse or neglect and felt safe there. She stated she had a call light and staff get to her as soon as they could. She stated she received her medication as scheduled. Observed 2 clear oblong pills laying on the bedside table, Resident #1 stated they were fish oil pills. Resident #1 stated staff leave her medication, peanut butter crackers, and water on the bedside table and do not watch her take her medications. She stated MA A administered her morning medications. In an interview on 11/20/24 at 10:40 AM MA A stated she has worked at the facility for 2 years. She stated she was delegated to pass medication. She stated when passing medication she matched the name to the medication, matched the medication dosage, and read the directions on the medication. She provided the medication with water, watched the resident take the medication, and checked off the medication on the MAR. She stated if the resident refused, she must notify the nurse. She stated she administered Resident #1's medication this morning and watched her take her medication. She stated she administered the medication to Resident #1 and walked back to the medication cart to document it in the MAR. As she was documenting she was overseeing the resident, she thought the resident had taken all her medications, so she moved on to the next resident . MA A stated she was responsible for making sure residents swallowed and took their medications. She stated leaving medications at the bedside may result in the resident not taking her medications. In an interview on 11/20/24 at 11:47AM the ADM stated staff were not supposed to leave any medications in the room. He stated the staff were supposed to stay with the resident and make sure the medications were swallowed. The ADM stated staff were educated on the medication administration process by the DON, the ADON, and the unit mangers. The ADM stated the risk for leaving medications on the resident's bedside table and not ensuring residents were taking medications could result in subtherapeutic effects of medications, missed medications, or a demented resident could wonder in the room and take the medications that were not theirs. In an interview on 11/20/24 at 12:09 PM the DON stated MA A never should leave medications on beside tables. She stated she has recently educated all nurses and medication aides on medication pass step by step instructions. She stated she was responsible for educating the staff on the medication pass policy. The DON stated all staff were responsible for passing medications and were checked off visually on skills annually by the DON. She stated negative effects included the resident may not take their medications. Record review of facility Inservice titled Medication Pass Process dated 11/01/2024 reflected staff were never to leave the medications in the room for the resident to take later. The in-service was signed by MA A. Record review of facility policy titled Administering Medications dated 2001 and Revised December 2012 reflected, Medications shall be administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on observations, interviews, and record review, the facility failed to have all residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, for 1 of 7 (Resident # 1) residents reviewed for care. The facility failed to provide a clean comfortable environment for Resident #1 by allowing him to lay in a soiled bed . This failure could place residents at risk for further skin integrity impairment, untreated medical issues, and diminished quality of care. Findings included: Record review of Resident #1's Admission Record dated 07/17/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), anxiety (an emotion which is characterized by an inner turmoil and includes feelings of dread over anticipated events), seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), and cerebral infarction (also known as ischemic stroke, pathological process that results in an area of necrotic tissue in the brain). Record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS (- Brief Interview for Mental Status) of 00 indicating Resident #1 could not complete the interview. Section GG-Functional Abilities and Goals reflected Resident #1 required substantial/maximal assistance with bathing and was independent with toileting hygiene and personal hygiene. Record review of Resident #1's care plan which initiated on 01/27/23 and was revised on 07/27/23 reflected Resident #1's focus: has an ADL Self Care Performance Deficit r/t Alzheimer's, muscle weakness. Had a history of a right hip fracture, a goal: will be cleaned, well-groomed, appropriately dressed and weight maintained through next review date, and interventions requires extensive assistance X2 staff to use toilet, required extensive assist X1 staff with personal hygiene care, and requires extensive assist X2 staff with transferring. The care plan also reflected Resident #1 requires supervision of 1 staff to eat. A second focus area within the care plan reflected Resident #1 had an actual impairment of the skin with an intervention to Keep the skin clean and dry. Record review of Resident #1's weekly skin review dated 7/15/24 reflected Resident #1 had open wounds to his right buttocks, posterior (back) scrotum, and his lower sacrum. Resident #1 received wound care daily by the nurse and being followed weekly by the wound physician. In an observation on 7/17/24 at 10:15am revealed Resident #1 was lying in bed. His sheets were saturated with fluid, and an empty carton of milk was lying on the foot of the bed. Resident #1 opened his eyes only to say hello then shut them again. His call light was observed on the floor to the right-hand side of the bed. In an interview on 7/17/24 at 10:24am with the ADON, she stated she expected call lights to be at bedside and in reach of residents and sheets on the bed should be dry. Staff were educated by in-service every month and as needed related to residents having their call light within reach and keeping residents clean and dry. If the call light were to remain out of reach the residents could fall or have an injury related to not being able to get assistance or not be clean and dry. In an interview on 7/17/2024 at 11:08am with LVN A, she stated she had worked in the facility for about a month. She stated she was in-serviced regularly on abuse and neglect, resident rights, medication administration, ADL care, falls/fall prevention. She stated residents' sheets should be clean and dry. She stated it was common knowledge to ensure residents had clean and dry linens, including sheets. She stated if a resident were to lay in soiled or wet sheets for a period, it could cause bed sores. In an interview on 07/17/2024 at 11:22am with CNA A, she stated residents should be changed, turned, and repositioned every 2 hours and as needed. She stated if a resident was gotten out of bed, they should still be checked and changed every 2 hours and as needed. She stated residents' sheets should be clean and dry. She stated she was trained on linen care and ensuring residents had clean and dry linens, including sheets. She stated if resident were to lay in soiled or wet sheets for a period, it could cause bed sores. In an interview on 07/17/2024 at 11:55am with ADM and DON, they stated if a call light was not in a resident's reach, the resident could possibly have a delay in care or a fall. They stated residents' sheets should be clean and dry. They stated staff were trained on linen care and ensuring residents have clean and dry linens, including sheets. They stated if resident were to lay in soiled or wet sheets for a period, it could cause skin breakdown. Record review of facility policy titled Quality of Life-Dignity dated October 2009 reflected each resident shall be cared for in a manner that promotes and enhances quality of life. Record review of facility policy titled Routine Resident Checks dated December 2007 reflected Staff shall make routine resident checks to help maintain residents' safety. Routine residents check involves entering the resident's room and or identifying the resident elsewhere on the unit to determine the resident's needs are being met identifying any change in the resident's condition, identifying whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance etc.

Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 9 residents (Residents #1 and #2) reviewed for resident rights. The facility failed to ensure Resident #1 and #2's call lights were within reach on 07/17/24. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #1's Admission Record dated 07/17/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), anxiety (an emotion which is characterized by an inner turmoil and includes feelings of dread over anticipated events), seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), and cerebral infarction (also known as ischemic stroke, pathological process that results in an area of necrotic tissue in the brain). Record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS of 00 indicating Resident #1's cognitive level would not allow him to complete the interview. Section GG-Functional Abilities and Goals reflected Resident #1 required substantial/maximal assistance with bathing and was independent with toileting hygiene and personal hygiene. Record review of Resident #1's care plan which initiated on 01/27/23 and was revised on 07/27/23 reflected Resident #1's focus: had an ADL Self Care Performance Deficit r/t Alzheimer's, muscle weakness. Had a history of a right hip fracture, a goal: will be cleaned, well-groomed, appropriately dressed and weight maintained through next review date, and interventions: reflected extensive assistance X2 staff to use toilet, requires extensive assist X1 staff with personal hygiene care, and requires extensive assist X2 staff with transferring. In an observation on 07/17/24 at 10:15 AM revealed Resident #1's call light was observed on the floor to the right-hand side of the bed and out of the resident's reach. Resident #1 was lying in bed. Resident #1's sheets were saturated with milk, and it appeared the resident had spilled his milk. Observed an empty carton of milk which was lying on the foot of the bed. Resident #1 opened his eyes only to say hello then he shut them again. Record review of Resident #2's Admission Record dated 07/17/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood), anxiety (an emotion which is characterized by an inner turmoil and includes feelings of dread over anticipated events), and nontraumatic subdural hemorrhage (a rare condition that occurs when blood collects between the dura mater and arachnoid mater of the meninges surrounding the brain). Record review of Resident #2's Quarterly MDS dated [DATE] reflected a BIMS of 03 indicating Resident #2 had severe cognitive impairment. Section GG-Functional Abilities and Goals revealed Resident #2 required partial/moderate assistance with bathing, toileting hygiene, and personal hygiene. Record review of Resident #2's care plan which initiated on 08/01/23 and was revised on 08/23/23 reflected Resident #2's focus: had an ADL Self Care Performance Deficit r/t DX: Dementia, a goal: will be cleaned, well-groomed, appropriately dressed and weight maintained through next review date, and interventions: requires assistance X1 staff to use toilet, required extensive assistance X1 staff member with personal hygiene care, and requires physical assistance X1 staff member with transferring. In an observation and interview on 07/17/24 at 10:19 AM reveled Resident #2's call light was laying lying on the nightstand, out of the resident's reach. Resident #2 was observed in bed and stated everyone was treating him well. He stated he would just yell out if he needed help. In an interview on 07/17/24 at 10:24am, the ADON , she stated she expected call lights to be at bedside and in reach of residents. She stated staff were educated and in-serviced every month and as needed related to having their call light within reach. She stated if the resident's call lights were out of reach, the residents could fall or have an injury related to not being able to get assistance or not being clean and dry. In an interview on 07/17/2024 at 11:08 AM, LVN A stated residents' call lights should without a doubt be in their residents reach at all times. She stated she had been trained on call light placement. She stated if a call light was not in a resident's reach, it could cause a fall or some kind of trauma. In an interview on 07/17/2024 at 11:22 AM, CNA A stated residents' call lights should be in the residents reach at all times. She stated she had been trained on call light placement. She stated if a call light was not in resident reach, it could cause a resident to fall due to them reaching for it or could cause the resident to be in danger. In an interview on 07/17/2024 at 11:33 AM, CNA B stated residents' call lights should be in the residents reach at all times. She stated she had been trained on call light placement. She stated if a call light was not in resident reach, it could cause a fall. In an interview on 07/17/2024 at 11:42 AM, LVN B stated residents' call lights should be in residents their reach at all times. She stated she had been trained on call light placement. She stated if a call light was not in resident reach, it could cause a fall or harm to a resident. In an interview on 07/17/2024 at 11:42 AM, the DON stated residents' call lights should be in residents their reach at all times. She stated staff had been trained on call light placement. She stated if a call light was not in residents reach, a resident could possibly have a fall. In an interview on 07/17/2024 at 11:48 AM, the ADM stated residents' call lights should be in residents their reach at all times. He stated staff had been trained on call light placement. He stated if a call light was not in the residents reach, it could cause a resident to possibly have a delay in care. Record review of facility's policy titled Answering the Call Light dated 2001 (revised March 2012) revealed The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interviews and record review the facility failed to provide adequate supervision and to prevent accidents for one resident (Resident #1) of four reviewed for accidents and hazards. The facility failed to supervise Resident #1 when she was sitting at the nurse's station, which resulted in a fall with injuries on [DATE]. This failure placed residents at risk of accidents or falls resulting in injuries, pain, and hospitalization . Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic Kidney Disease, Dementia, Anemia (low iron in blood), Hyperlipidemia (high cholesterol), Glaucoma (eye disorder that clouds vision) and muscle weakness. Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of zero (0) suggesting severe cognitive impairment. Review of MDS section Functional Abilities and Goals reflected resident used a wheelchair for a mobility device. Further review of this MDS section reflected resident needed substantial/maximum assistance for wheelchair mobility to wheel 50 feet with two turns. Review of Resident #1's undated care plan reflected the problem [Resident #1] is high risk for falls r/t DX Dementia with interventions be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. Ensure a safe environment, floors even and free from spills or clutter, adequate light, bed in low position, personal items within reach, Maintain a clear pathway, free of obstacles. Further review of care plan reflected another problem [Resident #1] has had an actual fall r/t Cognitive impairment [DATE] fall w/o injury, [DATE] fall w/o injury, [DATE], fall w/injury with interventions Falling star program, place fall mat at bedside, PT/OT consult for strength and mobility as needed, [DATE]: sent to ER for further eval. Review of Resident #1's fall assessment dated [DATE], reflected a score of 19 indicating Resident #1 was High Risk for falls. Review of Resident #1's progress notes dated [DATE] at 9:41 pm, but effective [DATE] at 7:45 pm by LVN A, reflected SN down hall passing medication and was called by kitchen staff that patient was in floor near nursing station. When SN arrived at nursing station patient was noted to be on floor near wheelchair. SN and other nursing staff removed patient from floor after assessment completed and patient noted to have a hematoma to the right forehead with scant blood at site. Patient transferred to room via wheelchair. While in room adjusting patient in bed patient noted to have closed eyes and when called by name, patient was unresponsive and showing no sign of life. 911 called and SN with assist of other nursing staff started CPR. Paramedics arrived and took over CPR administration. During an interview on [DATE] at 12:55 pm, FM stated they received a call from the AD at the facility on [DATE] and were told Resident #1 had been left unattended at the nurse's station and fell out of her wheelchair. He stated he was told the nurse got called away to another room and someone in dietary found her on the floor. They had no idea how long she was on the floor. He stated he had been up there that day at lunch time from about 12:15pm to almost 2PM and he fed Resident #1, and she acted very normal to him. He stated, she was doing well, had no heart issues, nothing, but did have a history of falls. During an interview on [DATE] at 1:43 pm, the ADON stated she was not working the night Resident #1 fell , but she reviewed the incident report the next day, [DATE]. She stated she was aware Resident #1 was often at the nurses station because she was a fall risk, but she was not set up to be 1:1, not required to be 1:1. When asked what she would have done in a similar circumstance she stated she would have made sure the wheelchair was locked and the resident was properly positioned in her wheelchair. She stated, I would walk away, but it would depend on how long I would be gone. If I was just going to help an aide change a brief, then it would be okay to walk away . but if I was doing a med pass that would be different because I would be gone for longer period of time .every situation is different . During an interview on [DATE] at 2:14 pm, LVN A stated she was the nurse on the 300 hall on the evening of [DATE]. She stated she had been sitting at the nurses station and Resident #1 was sitting in her wheelchair up at the nurses station. She stated she had gotten up to go down the hall and pass meds and a few minutes later a staff member was calling out for help. She went down to the nurse's station and Resident #1 was lying on her side on the floor and she was bleeding from her head. She stated it was a moderate amount of blood and there was a bump on her head. She stated Resident #1 was conscious and her eyes were open at that time. She assessed her for injuries and then her and other staff put her back in her wheelchair and took her to her room. When they got to Resident #1's room, they moved her from her wheelchair to the bed. At that point, the resident became lethargic and stopped responding. She stated one of the staff called 911 and she went and got the crash cart and then started CPR. LVN A revealed she had received training on falls and fall prevention and knew Resident #1 was a fall risk. When asked why she had left Resident #1 alone at the nurses station she stated, there were other people there and thought they would keep an eye on her. She stated she had not told anyone she was going down the hall to have a conversation with anyone or to keep an eye on Resident t#1. She admitted that the charge nurse was responsible for the residents. She further stated that if a resident was a fall risk and was left unattended they could fall, they could get hurt, go to the hospital. They can get hurt really bad. She stated she felt the fall could have been prevented if Resident #1 had been on 1:1 monitoring . During an interview on [DATE] at 2:46 pm, DA -B stated he had been working on the evening of [DATE] and had been making rounds passing out resident snacks. He stated when he got to the 300 hall nurse's station, about 7:45 pm, he saw a resident lying on the floor on her side, not moving. He stated he called down the hall for help and LVN A came out of one of the rooms. He stated LVN A immediately went to the resident and checked her out and then asked him to go get the nurse on the 100 hall, so he did. He further stated that he could not see if the resident was injured or bleeding because her back was to him when he saw her. He stated he clocked out shortly after that and did not see what else happened. During an interview on [DATE] at 3:35 pm, CNA C stated she had been working at the facility a month and often worked the hall that Resident #1 was on and was familiar with the resident. She stated Resident #1 was always getting up out of bed and her chair - all the time. She stated they had to keep an eye on her because if they didn't she could get up and fall. They kept her bed low and fall mats in place when she was in bed. She stated, it's everyone's responsibility to watch residents but ultimately it's the charge nurse's responsibility. She stated Resident #1 was often in her wheelchair at the nurses station so everyone could keep an eye on her . During an interview on [DATE] at 4:20 pm the DON stated she was familiar with the fall incident with Resident #1 on [DATE]. She stated she was called that night and was told Resident #1 fell and had a bump on her head and a scant amount of bleeding. She stated she had seen Resident #1 at the nurses station often and knew she was a fall risk, and this was done for safety - to keep eyes on her. The DON stated all the staff were responsible for the resident's but ultimately the nurse on the hall was responsible. She stated she felt staff responded well to the incident, but she didn't get a lot of detail until the next day. When the DON was asked how she felt about Resident #1 being left unattended at the nurses' station she stated Doesn't make me happy. We need to keep an eye on them, and we didn't do what we needed to do. She further stated she felt it could have been prevented if they had kept eyes on her. She also stated if residents that are high fall risk are not supervised, they can fall, get injured and have to go to the hospital . When asked what she might have done in the same situation she replied, I would have taken her down the hall with me . During an interview on [DATE] at 5:12 pm, the AD stated he was aware of the fall incident on [DATE] with Resident #1 and that she had fallen while seated up at the nurse's station in her wheelchair. He stated he had been notified of the fall that evening but did not get the full picture. He stated, all I was told is she fell , got hurt and we are sending her out. He stated he did not find out about Resident #1 becoming lethargic or them doing CPR until the next morning, [DATE]. He stated the staff knew she was a high fall risk and they had put interventions in place when she did fall. He stated Resident #1 was not on 1:1 monitoring. He stated he did tell the FM the nurse was initially at the nurse's station and then went to pass meds and got called in a room. When asked how the incident was handled by staff after the fall, he stated I think they did a good job. When asked if there was something the staff could have done to prevent the fall, he stated no. The AD stated we all are responsible for the residents. He stated CNAs provide direct care and they would to tell the charge nurse if something was going on with a resident and the charge nurse was ultimately responsible for the residents. He stated his expectation of staff supervision with high fall risk residents was making sure all interventions are in place - reporting in the morning meeting so they can be identified; we have the fall prevention program, use low beds, mats, and call lights . Review of facility policy Safety and Supervision of Residents dated [DATE] reflected Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Further, Individualized, Resident-Centered Approach to Safety, 1. Our individualized, resident center centered approach to safety addresses safety and accident hazards for individual residents .3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse or neglect, including injuries of unknown source, were e reported immediately, or not later than 24 hours to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one (1) resident (Resident #1) of seven (7) residents reviewed for abuse and neglect. The facility failed to report Resident #1's fall on [DATE], which resulted in a head injury, in a timely manner to the State. This failure could place residents at risk for abuse, neglect, and a decreased quality of life. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic Kidney Disease, Dementia, Anemia (low iron in blood), Hyperlipidemia (high cholesterol), Glaucoma (eye disorder that clouds vision) and muscle weakness. Review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of zero (0) suggesting severe cognitive impairment. Review of MDS section Functional Abilities and Goals reflected resident used a wheelchair for a mobility device. Further review of this MDS section reflected resident needed substantial/maximum assistance for wheelchair mobility to wheel 50 feet with two turns. Review of Resident #1's undated care plan reflected the problem [Resident #1 ] is high risk for falls r/t DX Dementia with interventions be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. Ensure a safe environment, floors even and free from spills or clutter, adequate light, bed in low position, personal items within reach, maintain a clear pathway, free of obstacles. Further review of care plan reflected another problem [Resident #1] has had an actual fall r/t Cognitive impairment [DATE] fall w/o injury, [DATE] fall w/o injury, [DATE], fall w/injury with interventions Falling star program , place fall mat at bedside, PT/OT consult for strength and mobility as needed, [DATE]: sent to ER for further eval . Review of Resident #1's fall assessment dated [DATE], reflected a score of 19 indicating Resident #1 was at High Risk for falls. Review of Resident #1's progress notes dated [DATE] at 9:41 pm but effective [DATE] at 7:45 pm by LVN A reflected SN down hall passing medication and was called by kitchen staff that patient was in floor near nursing station. When SN arrived at nursing station patient was noted to be on floor near wheelchair. SN and other nursing staff removed patient from floor after assessment completed and patient noted to have a hematoma to the right forehead with scant blood at site. Patient transferred to room via wheelchair. While in room adjusting patient in bed patient noted to have closed eyes and when called by name, patient was unresponsive and showing no sign of life. 911 called and SN with assist of other nursing staff started CPR. Paramedics arrived and took over CPR administration . During an interview on [DATE] at 4:20 pm, the DON stated she was familiar with Resident #1's fall incident on [DATE]. She stated she knew Resident #1 was a fall risk and had seen her at the nurse's station. She stated, I saw her up there often. She stated staff often brought her up to the nurse's station in her wheelchair, for safety - to keep eyes on her. The DON stated she was told the resident had an unwitnessed fall out of her wheelchair and was found on the floor. She had a bump on her head and a scant amount of bleeding . The DON stated she wasn't sure if it was reported. She stated the AD would be the one responsible for reporting. During an interview on [DATE] at 4:57 pm, the AD stated the Falling Star Program is something they initiated for HMG facilities to help prevent falls. He said it could include interventions like yellow stars by a resident's name, fall mats, low beds and other interventions as needed. He stated it was internal and not a documented program or procedure. During an interview on [DATE] at 5:12 pm, the AD stated they did not have a policy on Abuse, Neglect, and Exploitation but followed the state provider letter. He stated he was aware of the fall incident on [DATE] with Resident #1 and that she had fallen while seated up at the nurse's station in her wheelchair. He stated he had been notified of the fall that evening but did not get the full picture. He stated, all I was told is she fell , got hurt and we are sending her out. He stated he did not find out about Resident #1 becoming lethargic or them doing CPR until the next morning, [DATE]. He said he called the governing bodies about the incident (his boss) and they said let's wait for the hospital report. That's what was directed to me. He stated later on Monday, [DATE], he got the hospital report, and he gave it to the governing bodies, and they decided it was not a reportable incident because she might have had a heart attack that led to cardiac arrest. We all collaborated and that was the decision they made. I said what I had to say, gave my opinion. He further stated that the incident was not reported but it was investigated. He stated he was the one that completed the investigation, and he would have been the one responsible for reporting it to the state agency . Review of Provider Letter ,d+[DATE] reflected 2.1, A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect .Death due to unusual circumstances. Further review reflected incidents of suspected abuse or neglect with serious bodily injury should be reported immediately but not later than 2 hours, and incidents that do not result in serious bodily injury but involves a death under unusual circumstances should be reported immediately, but not later than 24 hours after the incident occurs.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Cook E and Dietary Aide F wore a hair restraint while in the kitchen. 2. The facility failed to properly label and date leftover food in one of one walk-in refrigerator. 3. The facility failed to ensure Dietary Cook E properly sanitized her hands between tasks. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: 1. Observation on 11/29/2023 between 8:30 AM - 9:00 AM revealed Dietary Cook E was standing over clean dishes, and food in a pan on the food prep table. She turned and began walking to the kitchen door leading to the dining room when surveyor entered the kitchen. Dietary Cook E had her hair pinned to the top of her head; however, she was not wearing a hair net. Observation on 11/29/2023 between 8:30 AM - 9:00 AM revealed Dietary Aide F was in the kitchen standing over clean dishes. Dietary Aide F had a head band around a portion of her hair. The top section of her hair was not covered by hair net or by the head band. 2. Observation on 11/29/2023 at 8:45 AM revealed the following: Leftover rice not in the original package was not labeled or dated. Nine left over sausage patties not completely wrapped in aluminum foil was not labeled or dated. Five pound left over mild cheddar cheese not completely covered with plastic wrapped was not labeled or dated and was stored in parmesan box. Left over parmesan cheese not in the original package and partially opened was not labeled or dated. Partially opened leftover approximately three inches ham slices were not in the original package was not labeled or dated. 3. Observation on 11/30/2023 at 10:35 AM revealed Dietary Cook E washed her hands and placed new pair of gloves on both hands. She began to prepare the puree chicken salad. She touched her pants, her arm and surveyor's shirt with her ring finger, middle finger, fore finger, and small finger on her right hand. Dietary Cook E did not change her gloves as she placed the chicken salad in the puree processor. Her fore finger and middle finger on her right hand touched the chicken salad as she placed it in the processor. Dietary Cook E continued the process of puree chicken salad and poured the puree chicken salad in sliver container to place in the refrigerator. In an interview on 11/29/2023 at 8:35 AM Dietary Cook E stated she was not wearing a hair net. She stated she was required to wear hair net when in the kitchen. She stated she did cook breakfast on 11/29/2023. Dietary Cook E stated hair may fall into food, cups, plates, or anything in the kitchen. She stated germs may be on the hair and if a resident had hair in their food the resident may have stomach problems such as vomiting or diarrhea. Dietary Cook E stated she had been in-serviced on wearing hair nets when in the kitchen. In an interview on 11/29/2023 at 8:40 AM Dietary Aide F stated she thought the hair band was covering all her hair and did not realize the top of her head was not covered. She stated she was expected for all her hair to be covered when in the kitchen. She also stated there was a possibility hair may fall on the clean plates to be used for the lunch meal. Dietary Aide F stated if a resident did swallow hair the resident may become ill with stomach problems such as vomiting from the germs may be on the hair. Dietary Aide F stated she had been in serviced to cover all her hair when in the kitchen. In an interview on 11/29/2023 at 1:17 PM the Registered Dietician stated all staff in the kitchen was required to wear hair nets. She stated if the staff was wearing hair wraps the hair was expected to be covered with the hair wraps. She stated if the hair wraps did not completely cover the staff's hair a hair net was required to be worn on the portion of the hair being exposed. Registered Dietician stated there was a potential of hair falling in food or on plates. She stated if a resident ingested the hair there was a possibility a resident may become physically ill with stomach issues such as vomiting and diarrhea. She also stated hair was contaminated. Registered Dietician stated all leftover foods in the refrigerator was required to be completely covered, labeled, and dated. She stated if leftover food was not labeled or dated and stayed in the refrigerator two or three weeks and was served to a resident the resident had a potential to become ill with a type of food borne illness such as food poisoning. She stated there was a possibility a resident may need to be assessed at the hospital. In an interview on 11/30/2023 at 10:50 AM Dietary Cook E stated the gloves on her right hand did touch her clothes, surveyor clothes and her arm. She stated she was expected to remove the gloves, wash her hands, and place new gloves on her hands. She stated it was a possibility germs and bacteria could have cross contaminated from her gloves onto the chicken salad when she accidentally touched the chicken salad. She stated a resident had a potential of becoming seriously ill such as vomiting and diarrhea from food poisoning. Dietary Cook E stated she had been in serviced on hand hygiene. In an interview on 12/01/2023 at 8:40 AM Dietary Manager stated all staff entering the kitchen was expected to wear a hair net. He stated a hair wrap was acceptable only if the hair wrap covered all the staff's hair. He stated if it did not cover all the staff hair, he expected the staff to also wear a hair net. He stated there was a possibility hair could fall in the food. He also stated hair was considered contaminated. Dietary Manager also stated hair may have bacteria on it and chemicals from hair products. He stated if a resident swallowed hair a resident may become ill with stomach issues such as diarrhea and vomiting. He stated if a resident was severely ill and became dehydrated the resident may need to be admitted to the hospital. Dietary Manager stated the staff was expected to change gloves and wash hands prior to placing new gloves on their hands whenever the gloves on their hands had contacted anything contaminated. He stated clothes would be considered contaminated. He also stated if the Dietary Cook E touched her clothes and another person clothes, she was expected to remove gloves, wash hands using soap and water prior to placing new gloves on her hands. He stated if the cook touched the chicken salad with the contaminated gloves there was a possibility germ from the gloves may transfer to the food. Dietary Manager stated there was a potential for a resident to become ill such as vomiting and diarrhea. He also stated any leftover food was required to be sealed, labeled, and dated. He stated any leftover food was required to be discarded within 48 hours. He stated if there was not a label or date on the leftover food the staff would not know when it was placed in the refrigerator. Dietary Manager also stated if the leftover food was not discarded and was in the refrigerator for approximately three weeks and staff served it to the residents there was a possibility a resident may become seriously ill with food poisoning. He stated if a resident had food poisoning the resident may need to be hospitalized . He stated all staff had been in serviced on hand hygiene, label and dating all foods, and wearing hair nets. In an interview on 12/01/2023 at 10:47 AM the Dietary District Manager of Healthcare Services stated he expected the staff to change gloves and wash hands with soap and water between each task or when the gloves touched anything considered contaminated such as clothes. He stated if the cook touched inside of the puree processor and touched the food being poured into the processor when wearing contaminated gloves there was a possibility the food may become contaminated. He stated if a resident at the contaminated food there was a potential the resident may become physically ill with a stomach virus. He stated a resident may need to be examined at the hospital if the resident had severe vomiting and diarrhea. He also stated all staff in the kitchen was expected to have all hair covered with hair net. He stated there was a possibility hair may fall into the food and if a resident ingested the hair there was a possibility a resident may become ill with a type of food borne illness. He also stated all left over food was expected to be completely sealed, labeled, and dated. He stated leftover food was expected to be discarded within 48 hours. He stated if the left-over food was not labeled or dated and left in the refrigerator approximately three or four weeks there was a possibility a resident may become ill with food poisoning. He also stated all staff had been in serviced on hand hygiene, properly storing food, and hair nets. Review of the facility's Policy on Staff Attire dated 10/2023 reflected all staff members will have their hair off the shoulders, confined in a hair net or cap and facial hair properly restrained. Review of the facility's Policy on Food Preparation dated 2/2023 reflected all staff will practice proper hand washing techniques and glove use. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Review of the facility's Labeling and Dating not dated reflected Guidelines for Label and Dating: leftovers must be labeled and dated with the date they are prepared and the use by date. The day of preparation or opening is considered day one when establishing the use by date. Guidelines food is properly stored, covered, and handled. Review of the FDA Food Code 2022, Section 2-402 Hair Restraints, 2-402.11 Effectiveness reflected Food employees shall wear hair restraints such as hair coverings or nets, beard restraints . that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service and single-use articles. Review of the FDA Food Code 2022, 3-501.17 Ready to eat, Time/Temperature control for safety food, date marking reflected food shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . 1) The day the original container is opened in the food establishment shall be counted as day 1, and 2)The day or date marked by the food establishment may not exceed a manufacturers use by date if the manufacturer determined the use-by date based on safety. Review of the FDA Food Code 2022 Section 2-301.14 When to wash reflected Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapped single service and single use articles and: A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; E) After handling soiled equipment or utensils F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for four of twenty-one (Resident # 41, Resident #45, Resident #50, and Resident #51) reviewed for ADL's. The facility failed to ensure Resident # 41's, Resident # 45's, Resident # 50's, and Resident # 51's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings included: 1. Record review of Resident #45's face sheet, dated 11/30/2023, reflected an 67 -year-old female admitted to the facility on [DATE] with diagnoses which included type one diabetes mellitus with ketoacidosis without coma, (develops when your body does not have enough insulin to allow blood sugar into your cells for use as energy), muscle weakness (when full effort does not produce a normal muscle movement) and, unspecified lack of coordination (a muscle control problem that causes inability to coordinate movements). Record review of Resident #45's Quarterly MDS assessment, dated 09/30/2023, reflected Resident # 45 was rarely/ never understood. Resident #45 was assessed to have poor short- and long-term memory recall. She was not able to recall current season, location of own room, staff names/faces, and that she was in a nursing home. Resident #45's decision making abilities were poor. She had difficulty focusing and was easily distracted. She did not reject care. Resident #45 required extensive assistance with personal hygiene and was total dependent on staff for bathing. Record review of Resident #45's Comprehensive Care Plan, dated 11/01/2023, reflected Resident #45 had an ADL self-care performance deficit. Intervention: Resident #45 required extensive assistance with personal hygiene. Observation on 11/29/2023 at 9:03 AM, reflected Resident #45 was lying in bed. She had embedded blackish substance underneath all nails on her right hand. In an interview on 11/29/2023 at 9:05 AM, Resident #45 did not speak or respond verbally or with gestures to any of the questions. Observation on 11/30/2023 at 10:03 AM, Resident #45 was lying in bed. She had embedded blackish substance underneath all nails on her right hand. Her right hand near her fingernails had an odor of feces. In an interview on 11/30 2023 at 10:5 AM Resident #45 did not communicate verbally or with gestures. 2. Record review of Resident #51's face sheet, dated 11/30/2023, reflected a 67 -year-old female admitted to the facility on [DATE] with diagnoses which included osteoarthritis, unspecified site (joint disease-occurs most frequently in the hands, hips, and knees), generalized muscle weakness (when full effort does not produce a normal muscle movement), and Alzheimer's disease (affects memory, thinking and behavior). Record review of Resident #51's Quarterly MDS assessment, dated 08/14/2023, reflected Resident # 51 had a BIMS score of 0 which indicated residents' cognition was severely impaired. She did not reject care. Resident #51 required extensive assistance with ADLs. She was dependent on staff for all her bathing needs. Record review of Resident #51's Comprehensive Care Plan, dated 11/02/2023, reflected Resident #51 had an ADL self-care performance deficit. Intervention: Resident #51 required extensive assistance with personal hygiene. Observation on 11/29/2023 at 9:23 AM, reflected Resident # 51 was lying in bed. Her fingernails on her right hand were jagged and long. Resident #51 had blackish hard substance underneath all nails on her right and left hands. In an interview on 11/29/2023 at 9:25 AM, Resident #51 did not communicate verbally or with gestures. Observation on 11/30/2023 at 10:10 AM, Resident #51 was lying in bed. Her fingernails on her right hand were long and jagged. She had blackish hard substance underneath all nails on her left and right hands. In an interview on 11/30/2023 at 10:12 AM, Resident #51 did not communicate verbally or with gestures. 3. Record review of Resident #50's face sheet, dated 11/30/2023, reflected a 76 -year-old female admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus with unspecified complications ( a disease that occurs when a person's body does not use insulin effectively), need for assistance with personal care (person cannot fully care for themselves), age- related osteoarthritis (person cannot fully care for themselves), muscle weakness (when full effort does not produce a normal muscle movement), and arthropathy (medical condition that causes inflammation in the joint region). Record review of Resident #50's Quarterly MDS assessment, dated 10/28/2023, reflected Resident # 50 was rarely/never understood. She had poor short- and long-term memory recall. Resident #50 unable to recall the current season, the location of her room, staff names and faces, and that she was living in a nursing home. She did not reject care. Resident #50 required assistance with personal hygiene. Record review of Resident #50's Comprehensive Care Plan, dated 09/22/2023, reflected Resident #50 had an ADL Self-Care performance deficit. Intervention: Resident #50 required extensive assistance of two staff participation with personal hygiene. Observation on 11/29/2023 at 9:44 AM, reflected Resident #50 was sitting in her wheelchair waiting to be transferred to dialysis. Resident # 50 had a black substance underneath her forefinger and ring finger on her right hand. Her middle finger, forefinger, and ring fingernails on her right hand were long and jagged. In an interview on 11/29/2023 at 9:45 AM, Resident #50 did not communicate verbally or using gestures. Observation on 11/30/2023 at 10:16 AM Resident #50 was lying in bed. Her middle finger, forefinger and ring finger on her right hand had a black substance underneath the nails and these nails were long and jagged. In an interview on 11/30/2023 at 10:18 AM Resident #50 did not communicate verbally or with gestures. 4. Record review of Resident #41's face sheet, dated 11/30/2023, reflected an 77 -year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 1 diabetes mellitus with diabetic neuropathy unspecified, (destruction of insulin- producing pancreatic beta cells and neuropathy is a type of nerve damage that can occur if you have diabetes), need assistance with personal care ( person cannot fully care for themselves), muscle weakness (when full effort does not produce a normal muscle movement), unspecified lack of coordination (a muscle control problem that causes inability to coordinate movements) and, dementia ( impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #41's Quarterly MDS assessment, dated 09/15/2023, reflected Resident # 41 had a BIMS score of 5 which indicated residents' cognition was severely impaired. Resident #41 did not reject care. Resident #41 required extensive assistance with personal hygiene and was total dependent on staff for bathing. Record review of Resident #41's Comprehensive Care Plan, dated 09/20/2023, reflected Resident #41 had an ADL self-care performance deficit related to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Interventions: personal hygiene Resident #41 required assistance of one staff. Observation on 11/29/2023 at 10:17AM, reflected Resident #41 was lying in bed. She had blackish hard substance underneath each nail on her right and left hand. In an interview on 11/29/2023 at 10:19 AM, Resident #41 stated my nails are dirty and needed someone to clean them. I do not know who to ask to clean my nails. She changed the subject when asked if she reported her dirty nails to anyone. Observation on 11/30/2023 at 10:03 AM, reflected Resident #41 was lying in bed. Her nails had blackish hard substance underneath each nail on her right and left hand. The blackish substance was above the tip of her middle fingernail on her right hand. In an interview on 11/30/2023 at 10:05 AM, Resident #41 stated I told the girl last night to clean my nails and she did not. She stated she did not know the girl's name. She stated I am tired and do not want to talk anymore. In an interview on 12/01/23 at 8:35 AM, LVN A stated the nurses was responsible to trim and clean all residents with diagnosis of diabetes nails. She stated it was the CNA's responsibility to clean and trim all other residents' nails. LVN A stated the CNAs report to nurses of any diabetic residents' nails needed trimmed or cleaned. She stated the nurses makes rounds and check residents with diabetes nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. LVN A stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the residents' nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility could be feces or any type of bacteria underneath the residents' nails. LVN A stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. LVN A stated if a residents' nails were long or rough a resident may scratch themselves and cause a skin tear and there was a possibility the skin tear become infected. LVNA stated she was not aware of any of these residents refusing nail care. She also stated she had been assigned to 300 hall where Resident #45, Resident #51, Resident #50 and Resident #41 resided. In an interview on 12/01/23 at 8:48 AM, LVN B stated it was the nurses and CNAs responsibility to trim, cut and clean residents' fingernails. She stated only the nurses can trim and clean residents with diagnosis of diabetes. LVN B stated if a resident's nails were jagged there was a possibility a resident my infect their skin if the resident scratched themselves and develop a skin tear. LVN B stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. She stated if a resident placed their finger in their mouth the feces could transfer from their fingers to their mouth. LVN B also stated if the resident swallowed the feces or other bacteria a resident may develop a stomach infection such as E. Coli (a bacteria that is commonly found in the lower intestine and can cause serious food poisoning) and the resident may need to be treated at the emergency room . She stated the symptoms of a stomach infection may include the following: diarrhea, vomiting and/or loss of appetite. Resident # 45, Resident #51, Resident # 50, Resident #41 would require assistance from staff with all their fingernail care. She stated she knew two or three of these residents were diabetics and the nurse would need to do their nail care. LVN B also stated the CNAs completed nail care during showers and the CNAs would notify the nurses at that time if a resident with diagnosis of diabetes needed any nail care completed. In an interview on 12/01/23 at 9:03 AM, CNA C stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed, and cleaned nails during showers, however, the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA C stated the nursing staff was expected to clean and trim residents' nails immediately if there were blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. She stated if the nursing staff waited until shower the resident had a potential of scratching themselves and develop a skin tear. She also stated it was a possibility the resident may get an infection from the skin tear. CNA C stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated a resident may need to be assessed at the emergency room if they became severely ill. She stated she had been in serviced on cleaning and cutting residents nails. CNA C stated she did not recall the date of the in-service. In an interview on 12/01/23 at 9:15 AM, The Director of Nurses stated if a resident had dirty nails such as a blackish substance there was a possibility of bacteria on their fingers and/or underneath the resident's nails. He stated there was a potential a resident could ingest bacteria from their fingernails into their mouth. He stated it depended on the type of bacteria of what type an illness a resident could receive from the bacteria. The Director of Nurses stated a resident potentially could become ill with stomach issues or any type of infection. He stated there was a possibility a resident may need to be assessed at the emergency room . He also stated a resident had a potential to scratch themselves and may develop a skin concern such as a skin tear and may develop an infection if the residents' nails were not trimmed properly. The Director of Nurses stated it was the nurse supervisor responsibility to monitor nursing staff to ensure residents were receiving proper nail care. He also stated the CNA's or Nurses was responsible cut, trim, and clean residents' nails. He also stated the nurses was responsible for the residents with diagnosis of diabetes. He stated the staff was required to trim, cut, and clean nails during their showers and as needed. In an interview on 12/01/23 at 10:15 AM, The Administrator stated the residents' nail care was the CNAs responsibility. He stated if a resident was a diabetic it was the nurse's responsibility. The Administrator stated nail care was expected to be taken care of when nails were visibly dirty or needed to be trimmed. He stated if the blackish substance was a certain type of bacterial a resident may become physically ill. He stated there was a possibility a resident may require medical care from the hospital and that depended on what type of bacteria a resident may ingest. He said it was the nurse supervisor's responsibility to monitor residents nail care. He also stated if a resident's nails were long and not smooth a resident may scratch themselves and cause a skin tear or a small scratch area on the skin. In an interview on 12/01/23 at 10:55 AM, CNA D stated she would report to a nurse if a resident with diabetes nails needed to be cut or cleaned. She stated the CNAs were responsible for all other resident's nail care such as cleaning, trimming, and filing the nails. She stated nail care was usually completed during showers or as needed. CNA D stated nail care was to be completed daily if a resident's nails were dirty. She also stated if a resident had a blackish/brownish substance underneath their nails it could be any type of germs. CNA D stated there was a possibility a resident may eat with their hands and the blackish substance may transfer from residents' hands to the food. She stated the resident may develop stomach problems such as nausea and vomiting. She stated it was a possibility a resident may need to be assessed at a hospital if it was severe. CNA D stated if a residents' nails were rough there was a possibility a resident may scratch themselves and develop a skin tear or could scratch their eyes and may develop an infection. She stated she had been in serviced to clean and trim residents' nails in the shower and/or as needed except for diabetic nails. She stated she did not recall when the last in-service on nail care was given by nurse supervisors. Review of the Facility Policy on Care of Fingernails, dated, 2010 reflected the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Gently remove the dirt around and under each nail with an orange stick. Do not trim nails below the skin line or cut the skin. Trim fingernails in an oval shape. Smooth the nails with a nail file or emery board.

Based on observations, interview and record review, the facility failed to respect the residents' right to personal privacy of medical records and medical treatment for 3 of 10 Residents (Residents #70, #94 and #46) reviewed for privacy. The facility failed to ensure LVN C protected confidential resident healthcare information for Residents #70, #94, and #46 by leaving the information uncovered on a yellow paper tablet on top of her medication cart. This failure could place residents at risk of personal information being exposed to unauthorized persons, loss of dignity, and low self-esteem. Findings included: Record review of Resident #70's Face Sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of Anoxic Brain Injury (brain cell damage due to lack of blood flow or decrease in oxygenation), Cardiac Arrest (sudden loss of heart function that leads to a lack of oxygen and nutrients reaching the brain and other tissues), Obstructive and Reflux Uropathy (blockage or obstruction in the urinary tract leading to a backflow of urine from the urinary bladder into the ureters and sometimes up into the kidneys). Record review of Resident #70's Quarterly MDS Section H dated 09/29/2023 reflected she had an indwelling catheter. Record review of a Care Plan dated 07/05/2022 for Resident #70 reflected she had an indwelling catheter related to Obstructive and Reflux Uropathy. Interventions: FC (Foley catheter) 20 French (indicating the external diameter of the catheter tube). Record review of Resident #94's Face Sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Cerebral Infarction (lack of adequate blood supply depriving brain cells of oxygen and vital nutrients causing them to die and Dysphagia (difficulty swallowing). Record review of a Care Plan dated 05/16/2023 for Resident #94 reflected she required tube feeding related to Dysphagia. Document report aspiration, abnormal breath/lung sounds. Record review of Resident #46's Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar, the body either doesn't produce enough insulin or it resists insulin) with unspecified complications. Observation on 11/30/2023 at 2:23 PM of a yellow lined paper tablet on top of the medication cart for 600 hall containing confidential medical information for three residents. Resident #70's confidential patient information stated Foley 20 Fr. (20 French indicating the external size of the indwelling urinary catheter). Resident #94 had her name and CXR/Congestion and a set of vital signs. and Resident #46 had information stating need Lantus insulin. In an interview on 11/30/2023 at 2:30 PM LVN G stated she had worked in the facility for a few days and was a new employee. She stated the yellow tablet she left unattended on top of her medication cart was her cheat sheet that she wrote resident information on prior to documenting it in their charts. She stated Resident #70 had an indwelling urinary catheter and Resident #94 had a CXR that morning and her vital signs were on the sheet, sShe stated Resident #46 needed his Lantus insulin reordered and she also wrote blood sugar results from that morning on the paper. She stated that medical information should not be exposed as it is confidential patient information. She further stated she had not been trained on patient confidentiality at the current facility but had been trained in the past. In an interview on 12/01/2023 at 10:32 AM ADON H stated she had worked at the facility for two years in that position and was the supervisor over the nurses for 600 hall. She stated anyone could have walked up and seen the confidential patient information left on the cart by LVN G. She stated her expectation was for nurses to keep everything with confidential information either closed or locked. She stated nurses could place a blank piece of a paper to cover the tablet or keep it with them. In an interview on 12/01/2023 10:36 AM with the Administrator who stated the nurse should not have allowed confidential information to be accessible to anyone walking by. He stated staff should safeguard resident information as it wasis a HIPAA violation. He stated the facility had given an in-service and training on confidentiality and LVN C had signed it. He stated his expectation was staff would ensure that resident information was always safeguarded and kept with them. Record review of a facility policy and procedure titled Confidentiality for Information dated December 2006, reflected Policy Statement: Our facility shall treat all resident information confidentially. Policy Interpretation and Implementation 1. The facility will safeguard all resident records, whether medical, financial, or social in nature, to protect the confidentiality of the information. 2. Access to resident medical records will be limited to staff and consultants providing services to the resident. (Note: Representatives of state and federal regulatory agencies have access to resident information without the resident's consent.)

Based on observation, interview, and record review, the facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature for 1 of (1) kitchen reviewed. The facility failed to ensure meals were served hot and at a safe appetizing temperature. This failure could place residents at risk of reduced quality of life, weight loss, and food-borne illness. Findings included: During an observation on 11-05-2023 at 12:25 PM, tray cart was observed on hall 200 full of plates and not passed out to residents. During an observation on 11-05-2023 at 12:25 PM, tray cart was observed on hall 300 full of plates and not passed out to residents. During an observation on 11-05-2023 at 12:54 PM, a couple of food trays were still observed needing to be passed to residents. During an observation on 11-05-2023 at 12:55 PM, Resident #2 attempted to eat food but returned to CNA C after being delivered cold. Resident # 2 stated to CNA C he was not able to eat cold food like that. During an observation on 11-05-2023 at 1:35 PM, surveyor temperature checks were done Resident # 3 's food plate. Carrots- 80.1 degrees Mashed potatoes 80.0 degrees Smothered turkey patty-82.1 degrees. During an interview on 11-05-2023 at 11:30 AM, Resident #6 stated that the food had always been served cold. Resident #6 stated the ADM had known for a while that the food was cold. Resident #6 stated she had been used to eating the cold food that was served. During an interview on 11-05-2023 at 11:45 AM, Resident #5 stated the food would be better if it wasn't cold. Resident #5 stated the facility staff all knew the food was cold and that it was no use to report if nothing had been done. Resident #5 stated the cold food had been served that way for a very long time and he was used to eating the food cold. During an interview on 11-05-2023 at 11:20 AM, RP for Resident #1 stated Resident #1 complained so many times about cold food being served. The cold food concerns was made to the ADM with nothing being done about it. There is no reason any residents should be eating cold foods and they would not want any of their family members eating cold food. During an interview on 11-05-2023 at 12:30 PM, Resident #4 stated the facility had been knowing they served cold food. Resident # 4 stated she don't make any reports about the cold food as nothing had been done. Resident #4 stated the food is not good when it is cold, and she just eat the cold food. During an interview on 11-05-2023 at 12:40 PM, Resident #7 stated that the food had always been given to her cold. Resident #7 stated she don't like cold food and she just eat anyway. Resident # 7 stopped answering the surveyor when trying to obtain information on whether she had reported the cold food to any staff. During an interview on 11-05-2023 at 12:44 PM, Resident #1 stated being served cold food was her concern. Resident #1 stated the food is not enjoyable when it is delivered, and she do not want to eat. Resident # 1 stated that she couldn't recall the nursing staff that she reported to when the food was cold and didn't want to eat. During an interview on 11-05-2023 at 12:55 PM, Resident #2 stated he is the resident council president and it had always been a problem with the facility serving cold food. Resident #2 stated it had been brought to the ADM and the kitchen manager's attention. Resident # 2 stated no one had done anything about it and the residents had been used to eating their food cold. Resident #2 stated residents stopped making concerns about it in the resident council meeting. Resident #2 stated, It's a shame that food is not desirable when food is brought to residents cold. Who wants to eat food that is supposed to be hot but cold. Resident #2 stated he is fortunate to order food from the outside of the facility, but other residents are not able to do that. Resident #2 stated, It was really sad that they could do people like that. Trays are cold because they are sitting in the hall waiting to be passed out to residents. Resident #2 stated he did not want the food tray that CNA B brought in because it was cold and not desired to be eaten that way. During an interview on 11-05-2023 at 1:05 PM, Resident #8 stated the food was always cold when served. Resident #8 could not recall how long the food had been served like that but stated It's been like that for a while. Resident #8 stated, food was not desirable cold and who want to eat cold food. Resident # 8 stated, She have family to bring her food but not all resident's families do that. Resident # 8 stated the ADM had been told about the cold food so many times and nothing had been done about it. During an interview on 11-05-2023 at 1:15 PM, CNA A stated that is known by the entire facility that the food is cold when being served to residents. CNA A stated that the cart the trays are being delivered on are not heat insulated to keep the food warm. CNA A stated when the kitchen staff delivered the trays to the halls a nursing staff checked the trays and signed off on them. CNA A stated no one was notified that the trays were on the halls because the nursing staff had returned to her job duties and the trays were just sitting there. During an interview on 11-05-2023 at 1:35 PM, Resident #3 stated that the food he was eating was cold and he just dealt with it. Resident #3 stated, What else could he do. Resident #3 stated he had been dealing with the cold food for so long he had got used to it. Resident # 3 stated, he got to eat so he ate it cold. During an interview on 11-05-2023 at 1:45 PM, Dietary Aide A stated the facility had been knowing the food was delivered to the resident's cold. Dietary Aide A stated she was responsible for delivering the food carts to the halls. Dietary Aide A stated that when the cart is delivered it is checked and signed off by a nursing staff. Dietary Aide A stated the ADM and kitchen Manager had been told too many times about the trays just sitting on the halls when she had delivered them. Dietary Aide A stated the food was getting cold because the carts were not insulated with heat to keep warm. Dietary Aide A stated that food would be cold when the resident received their food. Dietary Aide A stated many food trays had been returned back to the kitchen unwanted due to being too cold to eat. Dietary Aide A stated that it was not a kitchen issue the food temperatures are taken before plates are sent out of the kitchen. The kitchen manager knew the food was cold and it had been brought to his attention by residents and staff. Dietary Aide A stated management is well aware of the food being cold and nothing had been done about it. Dietary Aide A stated there were no microwaves in the kitchen to reheat any food. During an interview on 11-05-2023 at 1:56 PM, Kitchen Cook A stated that the food in the kitchen was not coming out cold. The food temperatures are checked before food is sent out to residents. Kitchen Cook A stated the plates are being prepared on a heated hot plate, but the food cart is not insulated for the food to stay warm. Kitchen Cook A stated that the Kitchen manager was well aware the food was getting cold on the floor waiting to be passed out to residents. Kitchen A stated They would not want to eat cold food so why let the resident's food sit and get cold? Kitchen Cook A stated the food trays are sent out on a cart that is not insulated which caused the food to get cold while sitting on the halls waiting to be passed out. During an interview on 11-05-2023 at 2:00 PM, Dietary Aide B stated that the facility had known that the food was sitting on the halls getting cold while waiting to be passed to residents. The Kitchen Manager was well aware of the cold food. Dietary Aide B stated she assisted Kitchen Cook A in preparing the trays and temperature checks completed before sending the trays out to the floor to be delivered. During an interview on 11-05-2023 at 2:15 PM, The Kitchen Manager stated his kitchen had no issue with food coming out cold. Kitchen Cook A checked temperatures before food was sent out to the floor. The Kitchen Manager stated no one had mentioned to him anything about cold food and he don't' feel his kitchen was responsible for food getting cold while sitting and waiting to be passed out. During an interview on 11-05-2023 at 3:19 PM, The ADM stated no one had told him anything about cold food. The ADM stated he observed the lids not securing the plated properly on 11-1-2023 at lunchtime and had ordered insulated carts and metal plates to keep the plates warm while being delivered to the residents. The ADM stated the carts now are not insulated and this could cause food to become cold while delivered to residents. ADM stated is he had been told about cold food he would had the problem fixed. During an interview on 11-05-2023 at 3:34 PM, CNA B stated residents had mentioned to her that the food was cold and they send it back to the kitchen. CNA A stated sometimes staff don't know food trays are on the halls and no one is notifying the staff that the trays are there. Once the trays are seen staff immediately start passing the trays out to residents. The food is cold because there are no insulated carts that the food are being kept in. CNA B stated she reported cold food to the kitchen staff. During an interview on 11-05-2023 at 3:56 PM, CNA C stated that Resident #2 refused his food when it was cold and she returned to the kitchen every time. CNA C stated it was known the food was being served cold. The food is sitting on the floor waiting for staff to pass out to residents. Once the kitchen staff brought it to the floor the nurse checked and signed off on it. The nursing staff who sign off return to their duties and no one is assigned to pass out the trays. CNA C reported a cold food complaint to the kitchen manager. During an interview with LVN A on 11-05-2023 at 4:20 PM, LVN A stated she checked trays and signed off. Once she signed off on she returned to her normal nursing duties without assigning staff to pass trays. LVN A stated it is known the food cart is not insulated which is causing the food to get cold when the food is not passed out timely. Review of grievances dated August, September, and October 2023 reflected no related grievances. Review of Resident Council dated August, September, and October 2023 reflected no related complaints on cold food. Review of facility policy dated revised December 2009 and titled Resident Nutrition Services reflected the following: Each resident shall receive the correct diet, with preferences accommodated as feasible, and shall receive prompt meal service and appropriate feeding assistance.

Based on interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of three residents (Resident #1 and Resident #2) reviewed for pain. - 1. The facility failed to manage Resident #1's and Resident #2's pain. - - 2. The facility failed to administer Resident #1's scheduled pain medication of Tramadol at the times ordered for pain by the physician and failed to administer his PRN hydrocodone to adequately control his pain, and the facility failed to care plan pain for this resident despite it triggering on his assessment. This failure caused the residents to experience avoidable pain that was severe, and more than transient lasting for weeks and put all residents at the facility at risk of suffering pain which could prevent them from achieving their highest practicable physical, mental, and psychosocial outcome. On 02/24/23 at 5:15 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/26/23 at 12:53 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures put all residents at the facility at risk of suffering pain that could prevent them from achieving their highest practicable physical, mental, and psychosocial outcome. Findings included: RESIDENT 1 Record review of Resident #1's undated face sheet printed on 02/23/23 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (sudden failure of lungs to deliver oxygen to the body), malignant neoplasm of the colon (colon cancer that has spread), major depressive disorder, anxiety disorder, human immunodeficiency virus (virus that kills immune cells, HIV) and malnutrition. Record review of Resident #1's Entry Minimum Data Set (MDS), dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section G Functional Status indicated Resident #1 was marked as being in need of one person physical assist for bed mobility, dressing, toilet use, and hygiene. Section J Health Conditions: Question J0100 revealed in the past 5 days the resident used scheduled pain medicine, PRN pain medicine, and non-medication intervention for pain Question J0400 revealed the resident reported pain frequently in the last 5 days Question J0500 revealed pain had made it hard for the resident to sleep and had limited his day-to-day activities over the past 5 days Section V Care Area Assessment showed that the care area of pain triggered in column A and column B was marked to indicate that the triggered area is addressed in the care plan Record Review of Resident #1's care plan, last reviewed 01/10/23, revealed the following: there was no focus area that addressed pain on the active care plan on 02/23/23 Record review of Resident #1's Physician Orders, undated, accessed 02/23/23, revealed: Order Type: Prescription Start Date: 12/16/22 End Date: Open Ended Description: Hydrocodone-acetaminophen tablet 5-325 mg, give 1 tablet by mouth every 4 hours as needed for acute pain Ordered by: MD Order Type: Prescription Start Date: 1/11/23 End Date: Open Ended Description: Methocarbamol Tablet 500 MG, Give 2 tablet by mouth as needed for Pain-Severe TID PRN with Norco administration Ordered by: MD Order Type: Prescription Start Date: 1/23/23 End Date: Open Ended Description: TraMADol HCl Tablet 50 MG, Give 1 tablet by mouth every 6 hours for Pain- Moderate-Severe Ordered by: MD Record review of Resident #1's Medication Administration Record for the month of January revealed that on 01/11/23 NP added Methocarbamol 500 mg x2 to be given PRN with hydrocodone. This medication was only administered twice since 01/11/23 through 02/23/23. Record review of Resident #1's Medication Administration Record for the month of February revealed that Resident #1 had scheduled tramadol every 6 hours and Norco every 4 hours prn. This medication was only administered 3 times in early February, PRN hydrocodone given 3 times, methocarbamol was not given, hydrocodone was given 2/1/23 8:38 am; 2/2/23 5:48 pm; 2/7/23 6:50 pm Record review of Resident #1's Medication Admin Audit Report, printed on 02/24/23 by request, revealed the resident's scheduled tramadol every 6 hours was administered at the following times: 2/1/23 tramadol scheduled at 6 am given 10:03 am 2/3/23 tramadol scheduled at 6 am given 11:02 am (next dose is scheduled at 12:00 pm and given at 12:02 pm) 2/9/23 tramadol scheduled at 6 am given 7:14 am 2/11/23 tramadol scheduled at 6 am given 7:44 am 2/23/23 tramadol scheduled at 12:00 pm given 1:21 pm 1/24/23 tramadol scheduled 12:00 am given 3:59 am 1/26/23 tramadol scheduled 12:00 am given 1:27 am 1/27/23 tramadol scheduled 12:00 am given 5:41 am (1/27/23 tramadol scheduled at 6:00 am given at 5:41 am as well) 1/28/23 tramadol scheduled 12:00 am not showed as given in records 1/31/23 tramadol scheduled 12:00 am given 2:41 am 2/2/23 tramadol scheduled at 12:00 am given 2:51 am 2/4/23 tramadol scheduled at 12:00 am given 5:10 am (2/4/23 tramadol scheduled at 6:00 am not showed as given in records) 2/5/23 tramadol scheduled at 12:00 am given 2:39 am 2/6/23 tramadol scheduled at 12:00 am given 5:10 am (2/6/23 tramadol scheduled 6:00 am given 5:10 am, same time as midnight dose) 2/8/23 tramadol scheduled at 12:00 am given 1:44 am 2/9/23 tramadol scheduled at 12:00 am given 4:08 am 2/10/23 tramadol scheduled at 12:00 am given 2:44 am 2/11/23 tramadol scheduled at 12:00 am given 7:44 am (2/11/23 tramadol scheduled 6:00 am given 7:44 am, same time) Record review of Resident #1's progress notes printed on 02/23/23 revealed 3 progress notes in January state the resident has uncontrolled pain. Record Review of Resident #1's progress notes revealed the following: 1/11/23 9:00 am prn norco given and stated resident complained of pain, no pain scale was documented tied to administration in notes 1/11/23 11:18 am a note stated the pain medicine administered was ineffective and the resident's pain was at a 7 out of 10 1/11/23 12:01 pm noted resident and family member complained of prn hydrocodone pain medication was not working . it further stated that the nurse practitioner added methocarbamol 1000 mg 3 times a day along with hydrocodone administration 1/22/23 5:30 pm noted that the resident was given methocarbamol and pain medication, but the MAR dated January 2023 shows no methocarbamol was administered 1/23/23 2:19 pm noted Resident #1's RP expressed concern that residents pain was not being managed with PRN medication the nurse practitioner was informed and tramadol was scheduled every 6 hrs with hydrocodone prn for breakthrough In an observation and interview with Resident #1 on 02/23/23 at 3:03 pm, Resident #1 expressed uncontrolled 10 out of 10 pain every day for several hours a day since he admitted to facility on 12/22/22. Resident expressed that the pain leads to crying. He was laying in the bed curled in the fetal position with his jaw clenched in a grimacing expression and arms tensely curled. During interview, the resident was noted to have watery eyes and a blanket tightly curled around his upper body and was trembling while we spoke. In an interview on 02/23/23 at 4:05 pm, with Family1 on the Sunday before January 18th (January 15, 2023), she kept a journal and writes down everything that happened, Resident #1 was told if you keep pushing that button you won't get anything. Family 1 stated that Resident #1 had severe pain on a regular basis that caused him to cry. She stated that she had voiced her concerns to Resident #1's care givers at the facility. When asked how it made him feel, she stated it caused him to stay in bed and worsened his depression. Family stated that Resident #1 discharged from the hospital after being on morphine and transitioning to hydrocodone (Norco) before arriving at the facility. Family 1 denied knowledge of the order for PRN hydrocodone (Norco) for pain. In an observation and interview with Resident #1 on 2/23/23 at 4:55 pm, Resident #1 confirmed that he was in excruciating pain and he clearly rated it at 10 out of 10, but stated it was not time for his medicine yet. When asked if he was able to get extra medicine between the scheduled medicine and he said no, the nurses told him he had to wait for his next scheduled dose of medicine. During the interview, was tearful with a clenched jaw and curled into a fetal position with a blanket clenched in his fists at chest level. Resident #1 indicated pain affects his daily life leading him to stay in his room alone. Resident #1 denied telling staff his pain was at a zero and stated staff do not ask him even once a day, much less every shift, if he was in pain. Resident #1 denied knowledge of an order that allowed PRN hydrocodone for breakthrough pain. In an interview on 2/23/23 at 5:17 pm with DON and ADM, DON stated that Resident #1 never hit the call light and asked for pain medicine. DON stated it is the MDS nurse's responsibility to ensure care area's that are triggered on the MDS are reflected in the care plan for the resident. Adm stated that the resident was very depressed and resists care and efforts to get the resident out of his room due to his depression. In an interview on 2/24/23 at 9:55 am with DON she stated that facility-wide rounds were done on all residents to assess for adequate pain management. She stated that she would check into why pain was not care planned for Resident #1. She also stated she would check why Methocarbamol was not provided to Resident #1 when he expressed, he was in pain despite the existing order and why the PRN hydrocodone was only administered 3 times in February. In an interview on 02/24/23 at 10:25 am with AD, she stated she saw Resident #1 every other day and has assisted him with showers, haircut, and redirection. She stated he was very shy, but she felt they had formed a connection; he stated that he liked cats, so she tried to find cat items for him like the cat calendar she put in his room. She stated he never mentioned pain, but during one of his showers in early January, she saw him bend over to pick something up and the expression on his face showed he was in pain, so she reported this to the nurse immediately after. In an interview on 02/24/23 at 4:24 pm with CNA C, she stated Resident #1 doesn't push button, he only pushes his light for pain medicine. Med aides start at front of hall; he may push button 3-4 times and she would answer and tell him Med Aides are on their way. In an interview on 02/24/23 at 4:49 pm with RN D, she stated that Resident #1 always asks for pain medication and doesn't want to leave room, he is always in bed, and every 4 hours he wants his pain medicine; usually after a pain med he states he is ok, but will need pain med in 4 hours; he never hits the button before the 4 hour mark this was since he admitted he hits button for med at 4 hours daily. She stated that the twice daily pain assessments should be documented every shift, entered at beginning of the shift by the nurse. When asked why a 0 was documented for a resident pain level when administration of hydrocodone was done and the pain level was documented at a 7, she stated she is unsure why the 7 did not show up on the tab for vitals on the medical record and why a 0 would show up instead. She said it is possible a CNA documented something after the nurse did and the record only kept what the CNA documented. In an interview on 02/24/23 at 3:30 pm with LVN B, She stated it was the responsibility of the floor nurse to document the level of pain every shift for residents with that order. She stated the aides are not qualified or trained to perform a pain assessment, so it must be a nurse. She stated if a resident notified a CNA about being in pain, the CNA should inform the floor nurse, nurse should do assessment, then reach out to doc and put progress note that physician contacted. In an interview on 02/27/23 at 5:59 am with LVN E, she stated that Resident #1 may hit his call light 45 min after a dose of pain medicine was given or 1:15 after dose given and it is explained he just got a pain med 45 min ago, she is not comfortable giving another dose. When sked if she offered his PRN medicine she stated she was unaware of that order. She works the night shift and when asked why his scheduled tramadol was not given at the proper times she stated that she has a routine she follows, but sometimes residents need more care and sometimes it is a glitch with the medical record system. She said it could be given late or it could be that she did not document the medication at the time it was given. RESIDENT 2 Record review of Resident #2's undated face sheet printed on 02/24/23 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included type 2 diabetes mellitus (inability to process sugar), end stage renal disease (kidney failure), neuropathy (nerve pain), chronic pain syndrome (persistent pain that can last years), sciatica (pain along the sciatic nerve that travel from the lower back to the hips and down the legs), major depressive disorder (depression), and generalized anxiety disorder. Record Review of Resident #2's care plan, last reviewed 10/24/22, revealed the following: Resident was at risk for pain r/t spinal stenosis and at risk for chronic and/or acute pain due to spinal stenosis (narrowing of the spinal column causing pressure on the spinal cord and nerve endings) and the following interventions are planned: - Administer analgesia as per orders - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain - Report to Nurse if resident complaints of pain or requests for pain treatment - Report to Nurse any s/sx of non-verbal pain: changes in breathing, moans, restless, grimacing, curled up, more irritable, crying, teeth clenched - Acknowledge presence of pains and discomfort. Listen to resident's concerns - Administer pain medication as per MD orders, observe side effects and note the effectiveness - Give PRN meds for breakthrough as per MD orders and note the effectiveness Record review of Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Section V Care Area Assessment showed that the care area of pain triggered in column A and column B was marked to indicate that the triggered area is addressed in the care plan. Record review of Resident #2's Physician Orders, undated, accessed 02/24/23, revealed: Order Type: Prescription Description: Hydrocodone-acetaminophen tablet 10-325 mg, give 1 tablet by mouth every 6 hours as needed for pain-Moderate Ordered by: MD Order Type: Prescription Description: Tylenol with Codeine #3 tablet 300-30, give 1 tablet by mouth every 4 hours as needed for Pain-moderate; Pain-severe Ordered by: MD Record review of Resident #2's progress notes, printed 02/24/23 revealed that he declined dialysis on the following days in February 2023, but did not document a reason for the declination: 02/03/23, 02/08/23, 02/13/23, 02/20/23; further review revealed a note on 02/18/23 at 9:05 am in a nursing note for the administration of prn hydrocodone that his back was in severe pain 9/10, he stated that when he is lying in bed flat it helps but when sitting its unbearable . The next progress note dated 02/18/23 at 9:42 am entered in a nursing note that the resident was still in his wheelchair nurse entered room to assess resident and noted resident slumped in w/c Resident was assisted back to bed by this nurse. In an interview on 02/24/23 at 10:48 am with Resident #2, he stated CNAs get overwhelmed which led to poor care. Several times he has asked for pain medicine, and it was not brought in; something in his back was very painful, and he asked for increase in dosage or frequency, as he is on hydrocodone every 6 hours. He stated the medicine brings his pain down to bearable pain (a 3 or 4 out of 10 was acceptable according to him), but just getting out of bed was horrible pain in the back for the last 10-12 days, and no one has come to evaluation. His hydrocodone was prn, so he has to ask, the staff never ask him if he needs it. He said he gets Tylenol 3 as needed, but it was not stopping his pain; he has not been asked if he was in pain twice a day despite it being ordered by his physician. Today at 5:15 am he asked for pain medicine and did not get it until after 6 am because nurses change shift at 6 am, so he was left in what he clearly stated was 10 out of 10 pain, and he has a high tolerance for pain. He stated in the last 2 weeks he missed at least 2 dialysis appointments that he would usually attend due to pain. Resident #2 stated he was in daily in pain; his right arm because his shoulder needed replacement and depending on the day it can also get achy; after he takes his hydrocodone his pain goes from a 10 to a 3 or 4 (which is acceptable for him), but about 3.5 hours later his pain comes back. He states he gets spasms in right upper leg stump daily, and he was allergic to gabapentin, so he was given Flexeril which was not helping much, and it was very bad in the morning times. He stated prior to admission he had to go to a pain clinic in Dallas to get injections that controlled his pain, but since he moved to the facility, he was no longer treated by a pain specialist. He stated he was experiencing a loss of range of motion in his right shoulder since he arrived. In an interview on 02/24/23 at 3:30 pm with LVN B, She stated it was the responsibility of the floor nurse to document the level of pain every shift for residents with that order. She stated the aides are not qualified or trained to perform a pain assessment, so it must be a nurse. She stated if a resident notified a CNA about being in pain, the CNA should inform the floor nurse, nurse should do assessment, then reach out to doc and put progress note that physician contacted. When asked if she was informed about back pain in Resident #2, she stated yes, she was told on 18th, but the resident said when laying down he was ok, he said I may have to go to the hospital, but he declined, and the provider was not notified. In an interview on 02/24/23 at 4:49 pm with RN D, she stated the Resident #2 declined dialysis on occasion, but she did not recall him declining dialysis recently and she did not inquire why he declined when he did. She stated some days he will ask some he won't, says it is effective; some days takes hydrocode and in 2 hrs still in pain needs Tylenol 3; never had a time he asked for pain meds and was not able to have because too soon; he gets pain, usually his stump from his amputation, usually he requests a shower and he is given one when he requests, maybe it does not show if not on schedule day? Usually goes the 2 days to dialysis that he states he needs. In an interview and observation an 02/26/23, Resident #2 was not found in his room and it was determined he admitted to the hospital for uncontrolled pain and dialysis. He was still out of the facility on 02/27/23. On 02/24/23 at 5:15 pm the Administrator, DON, and a corporate nurse consultant were notified that the facility would be placed in immediate jeopardy status for failure to provide adequate pain management. The following Plan of Removal submitted by the facility was accepted on 02/26/23 at 12:53 pm and read as follows: Impact Statement: On 2/23/23 an abbreviated survey was initiated at Red Oak Health and Rehabilitation at 101 [NAME] Drive, Red Oak TX 75154. On 2/24/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to protect 2 of 99 residents assigned to the charge nurses that day from being free of pain. What corrective actions have been implemented for the identified residents? 1. The following action items were implemented immediately on 2/24/23. a. Resident #1 record was reviewed by Director of Nursing on 2/24/23 with the resident's physician. The pain medication order for Hydrocodone 325mg was changed from PRN every Q4 hours to scheduled Q6 hours with PRN order for Tramadol 50 mg for breakthrough pain Q6 hours by on 2/24/23, with additional order for Methocarbamol 1000mg. If the pain is not relieved with the Tramadol 50 mg PRN. Resident's physician ordered Q4 hour pain assessment to be completed by licensed nurse, was scheduled 2/24/23 for Resident #1. Orders will be reassessed on 2/27/23 during the physicians next visit for Resident #1. At this time the physician will decide if the q 4-hour pain assessment will need to continue. The DON or Nurse manager will confirm on 2/27/23 that the physician did reassess patient. On 2/24/23 the pain assessment was completed and document in the resident electronic medication administration record every shift followed through as appropriate when patient verbalized pain was effectively addressed. Monitoring of completion of Q4 pain assessments will be conducted by a nurse manager as stated in 2.f. b. Resident #2 record was reviewed by Director of Nursing on 2/24/23 with the resident's physician. STAT kidney function labs ordered and x-ray to Lumbar spine on 2/24/23 and licensed nurse sent the order to the lab and received results 2/24/23 as confirmed by nurse manger on 2/25/23. Hydrocodone 10-325mg was ordered to be scheduled Q6 on 2/24/23 and continuing order for Tylenol #3 Q4 hours PRN which was originally ordered on 12/22/22. Q4 hour pain assessment to be completed by licensed nurse was scheduled 2/24/23 for Resident #2. Orders will be reassessed on 2/27/23 during the physicians next visit for Resident #1. At this time the physician will decide if the q 4 hour pain assessment will need to continue. The DON or Nurse manager will confirm on 2/27/23 that the physician did reassess patient. On 2/24/23 the pain assessment was completed and document in the resident electronic medication administration record every shift followed through as appropriate when patient verbalized pain was effectively addressed. Monitoring of completion of Q4 pain assessments will be conducted by a nurse manager as stated in 2.f. c. Resident #1 was assessed for pain by the Director of Nursing on 2/24/23 and resident stated he was at a pain level of 4 and that is his comfortable level. No concerns noted at this time. d. Resident #2 was assessed for pain at 16:00 at by Nurse Manger on 2/24/23 and resident stated he was at a pain level of 10. Nurse Manger reviewed residents' chart and identified that the last received pain medication, PRN Hydrocodone 10-325mg, was at 09:31am and his pain was re-assessed at 10:21 with results of pain level of 0. At this time charge nurse administered the resident's PRN medication Hydrocodone 10-325mg as order at 16:32 and re-assessed his pain at 17:36 with results of pain level of 0 pain level. e. On 2/24/23 a one-time pain assessment was completed by Nurse Mangers for all residents to ensure no other residents' pain was not being managed and that nurses were accurately assessing residents for pain with results of no residents reporting pain during their assessments other than resident #2 which was addressed as noted in 1.d. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. An in-service was initiated to licensed nurses on 2/24/23, by the Director of Nursing on assessing residents Q shift or as ordered for pain by charge nurse verbally asking the resident their pain level and observing for non-verbal ques for pain indefinitely. If pain is noted during the assessment the nurse is to review the resident's orders to identify if PRN pain medication order is in resident's chart. If the resident has a PRN pain medication order the nurse is to administer medication as ordered and re-assess resident 30-45 minutes post pain medication to ensure medication was effective. If the resident does not have a PRN pain medication ordered or if the current pain medication prescribed to the resident is not effective in managing the resident's pain, the nurse is to contact the resident's physician to obtain guidance on how to address the pain. b. Director of Nursing contacted licensed nurses on 2/24/23 to complete in-service on assessing residents Q shift or as ordered for pain by verbally asking the resident their pain level and observing for non-verbal ques for pain. If pain is noted during the assessment the nurse is to review the resident's orders to identify if PRN pain medication order is in resident's chart. If the resident has a PRN pain medication order the nurse is to administer medication as ordered and re-assess resident 30-45 minutes post pain medication to ensure medication was effective. If the resident does not have a PRN pain medication ordered or if the current pain medication prescribed to the resident is not effective in managing the resident's pain, the charge nurse is to contact the resident's physician to obtain guidance on how to address the pain. Nurses that are unable to come to the facility by 2/24/23 will be educated via phone by the DON by 2/25/23. Nurses unable to contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on 2/25/23 by staffing coordinator or nurse manager daily for 1 week or until determined effective to ensure all staff who have worked are in service prior to their shift. c. The facility DON or nurse manager will in-service new hires during orientation, on assessing residents Q shift or as ordered for pain by verbally asking the resident their pain level and observing for non-verbal ques for pain. If pain is noted during the assessment the nurse is to review the resident's orders to identify if PRN pain medication order is in resident's chart. If the resident has a PRN pain medication order the nurse is to administer medication as ordered and re-assess resident 30-45 minutes post pain medication to ensure medication was effective. If the resident does not have a PRN pain medication ordered, the nurse is to contact the resident's physician to obtain guidance on how to address the pain at the time pain was reported by the resident and order obtained will be carried out by the nurse receiving the order from the physician. Nurses that are unable to come to the facility by 2/24/23 will be educated via phone by the DON by 2/25/23. Nurses unable to contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on 2/25/23 by staffing coordinator or nurse manager daily for a week or until determined effective to ensure all staff who have worked are in serviced prior to their shift. d. How will the system be monitored to ensure compliance? f. The DON or nurse manager will review all pain assessments in the residents' EMAR Q shift to ensure all assessments are completed and document by the licensed nurse appropriate to addressed patient pain was effectively daily for 2 weeks starting 2/24/23. Any discrepancies identified will be addressed immediately and further education by the DON or nurse manager. g. Starting 2/24/23 the DON or nurse manager will interview residents daily for 2 weeks to ensure the licensed charge nurses are assessing for pain q shift and pain needs are addressed timely by the licensed nurse. Post the daily monitoring on 3/10/23 the DON/nurse manager will review pain assessments to ensure pain is addressed effectively 2x week X 6 weeks or until it is determined the metric is met. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. h. Administrator will review the pain assessment auditing and round on patients on a weekly basis to ensure nurse managers are following the plan of correction for six weeks or until it is determined the metric is met starting 2/24/23. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 2/24/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 02/27/23 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the immediate jeopardy. Record review of the facility policy Pain assessment and Management revised in April 2009 revealed: - Commitment to resident comfort - Modifying approaches as necessary - Recognizing influences of a resident's ability or willingness to express pain Record review of the facility policy Administering Pain Medications revised in April 2009 revealed: - Review the resident care plan to assess for any special needs of the resident - based on a facility wide commitment to resident comfort - document results of the pain assessment, medication, dose, route of administration, and results of the medication (adverse or desired) Record review of the facility policy dated 2005, revised April 2007, titled Abuse and Neglect - Clinical Protocol, under assessment and recognition, statement #5 stated examples of neglect include ignoring patient wishes . Under treatment/management it stated that management will institute measures to address the needs of the residents and minimize the possibility of abuse and neglect. Record review of the facility policy dated 2001, revised April 2009, titled Administering Pain Medications, the purpose was stated as assessing resident's pain prior to administration of medication. The general guidelines state there is a facility-wide commitment to resident comfort. Statement 4 under general guidelines states be familiar with physiologic and behavioral (non-verbal) signs of pain. For example: A. Verbal expression such as groaning, crying, screaming B. Facial expressions such as grimacing, frowning, clenching of the jaw, etc; it continues with D. Behavior such as resisting care, irritability, depression, decreased participation in usual activities and G. Difficulty eating or loss of appetite and H. insomnia. Furthermore, statement 5 stresses that cultural or gender-specific influences may effect the resident's willingness to verbalize pain. For example, some cultures value stoicism and a high threshold for pain. Furthermore, statement 6 says acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained. Statement 7 says the pain assessment consists of gathering both subjective and objective data.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for two (Resident #3, and #2) of five residents reviewed for abuse. The facility failed to ensure Resident #3 and Resident #2 were provided goods and services necessary to avoid mental anguish and emotional distress because: - Resident #3 was left on the toilet on a daily basis, which caused emotional distress and embarrassment for the resident and discomfort for other residents hearing his distress - Resident #2 was not showered three times per week and was refused showers when he specifically asked to be showered This failure could place all residents in the facility at risk for emotional distress and mental anguish, which could prevent them from achieving their highest practicable physical, mental, and psychosocial outcome. Findings Included: RESIDENT 3 Record review of Resident #3's undated face sheet printed on 02/23/23 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included cerebral infarction (stroke), schizoaffective disorder (mental health condition including schizophrenia and mood disorder symptoms), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hemiplegia of the left side (loss of use of the left side of the body), dementia, and seizures. Record Review of Resident #3's care plan, last reviewed 11/29/22, revealed the following: Focus area ADL Self Care Performance Deficit r/t impaired mobility and the intervention was TRANSFER: I require 1-2 staff participation with transfers; further review revealed a focus area has flaccid Hemiplegia affecting non dominant side r/t Stroke with an intervention that was listed as Assist with ADLs/Mobility as needed. The care plan further revealed he had social services needs due to mood and behavior issues; the intervention listed was to identify the cause of behaviors and intervene. Record review of Resident #3's Annual Minimum Data Set (MDS), dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 07, which indicated the resident's cognition was severely impaired. Section G Functional Status: Toilet use was marked as requiring a one-person assist; Personal hygiene was marked as requiring a one-person assist; Moving on and off the toilet was marked as Not steady, only able to stabilize with staff assistance. The facility was asked to provide a policy regarding assistance with toileting during meal distribution on 02/24/23, but the facility failed to provide this policy. In an interview with Resident #3 on 02/23/23 at 1:08 pm, the resident stated that staff do not help him lay down when he wants to lay down at night. In addition, he can get to his toilet without assistance, but need help getting up from the toilet and the staff leave him on the toilet. He stated he is left for 30 minutes on the toilet which causes him to yell out and bang on the walls calling for help. The resident stated this occurs every day. He further stated that he feel humiliation, embarrassment and anger at being left on the toilet for extended periods daily. In an observation and interview with Resident #4 on 02/23/23 at 1:20 pm stated, without prompting, that he feels very bad because everyday Resident #3 gets his coffee in the morning then needs to use the toilet. He only needs assistance getting off the toilet because the stroke caused him not to be able to use his left side, so he needed assistance pulling up his pant when he is done and getting back to his wheelchair. Resident #4 whose room was on the same hall hears Resident #3 hitting the wall and yelling out for help every single day and this can go on for more than 30 minutes. He stated that staff are annoyed by Resident #3 who got in frequent arguments with staff and that was why staff would not help him. It angers and worries Resident #4 that Resident #3 was left every day in need of help. In an interview on 2/24/23 at 10:05 am with Family 2, she stated that she hears Resident #3 hitting the walls and asking for help from the restroom and she hears this frequently. She stated often times he needed help during the lunch hour and that was why no one would help him. She also stated that she has heard Resident #3 calling for help because he was laying in his bed and his call light was attached to the left side of his bed, which was the side that does not function due to his stroke. She stated Resident #3 had to yell to get another resident to push the button and get staff assistance. In an interview on 02/24/23 at 3:30 pm with LVN B, she stated that Resident #3 was very rude and derogatory to staff and other residents and described him as a bully. She stated his roommate moved to another room, but due to the different temperature preferences of the new roommate he returned to the room with Resident #3. She stated that Resident #3, either on purpose or not, needed assistance frequently during the lunch hour and per policy there cannot be any incontinent care while trays are distributed. In an interview on 02/24/23 at 4:24 pm with CNA C, she stated Resident #3 was very rude, foul mouthed, and he disturbed other residents; she stated he gets on toilet in the middle of a meal, and she can't help with toileting during a meal. He used the restroom a lot, and he started pounding on the wall, hits switch on wall, and started pounding immediately. RESIDENT 2 Record review of Resident #2's undated face sheet printed on 02/24/23 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included type 2 diabetes mellitus (inability to process sugar), end stage renal disease (kidney failure), neuropathy (nerve pain), chronic pain syndrome (persistent pain that can last years), sciatica (pain along the sciatic nerve that travel from the lower back to the hips and down the legs), major depressive disorder (depression), and generalized anxiety disorder. Record Review of Resident #2's care plan, last reviewed 10/24/22, revealed no care plan that addressed showering. Record review of Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Section G for Functional Status related to bathing revealed Resident #2 required 1 person to assist with bathing and showering. Record review of the facility grievance log dated November 2022 revealed that on 11/17/22 Resident #2 filed a grievance that he requested a shower and a nurse stated it was not his shower day; facility response stated resident had an accident when he returned from dialysis, which was during meal time, staff educated on resident right to PRN showers and resident educated on policy/incontinent care during meal times. Record review of the facility grievance log dated December 2022 revealed that on 12/16/22, Resident #2 stated that he had not received a shower in over a week, his last shower was 12/05/22; the facility response was that the resident would be given a shower after dialysis that day. Record review of Resident #2's Documentation Survey, requested 02/24/23, revealed CNA documentation of daily assigned tasks for Resident #2 which showed he had a shower on 02/20/23 and that he had not been showered since 02/06/23. In an interview on 02/24/23 at 10:48 am with Resident #2, he stated CNAs get overwhelmed which led to poor care. He stated that he finally got a shower on Monday, but it had been 11 days since his shower. He stated this happens frequently because he was scheduled for MWF shower and dialysis. When he returned from dialysis, he was tired and takes a nap then wished to have his shower and was refused because it should have been handled by day shift. Resident #2 indicated he was refused showers and he just wanted them to follow their word. He is frustrated and embarrassed that he has to beg to be showered. In an interview on 02/24/23 at 2:00 pm with DON, a shower log was requested and she stated the facility does not keep shower logs, they shower residents in A beds during the day shift and B beds during the night shift. When asked what about their preference, she said they use the schedule to keep the work load balanced for the aides. She stated that showers could be done on request, but this was not the standard policy. She reiterated that Resident #2 refuses showers, dialysis and meals frequently. In an interview on 02/24/23 at 3:30 pm with LVN B, She stated showers are decided by which bed the resident was in, that A beds are showered on the day shift and B beds were showered in the evenings. In an interview on 02/24/23 at 4:24 pm with CNA C, she stated showers at night seemed to be an issue, and she frequently has to give residents a shower in the morning because they did not get one on the night shift. In an interview on 02/24/23 at 4:49 pm with RN D, she stated the Resident #2 declined dialysis on occasion, but she did not recall him declining dialysis recently and she did not inquire why he declined when he did. In an interview and observation an 02/26/23, Resident #2 was not found in his room and it was determined he admitted to the hospital for uncontrolled pain and dialysis. He was still out of the facility on 02/27/23. Record review of the facility policy dated 2005, revised April 2007, titled Abuse and Neglect - Clinical Protocol, under assessment and recognition, statement #5 stated examples of neglect include ignoring patient wishes, recurrent failure to provide incontinent care. Under treatment/management it stated that management will institute measures to address the needs of the residents and minimize the possibility of abuse and neglect.

Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of six residents (Resident #53) whose records were reviewed for behavioral health services. The facility failed to ensure Resident #53 received behavioral health services including effective interventions for behavior disturbance which resulted in him being attacked by other residents twice in a two-day period. This failure could place residents at risk for injury and decreased quality of life. Findings included: Review of Resident #53's face sheet dated 09/27/2022 revealed Resident #56 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), paranoid schizophrenia (mental disorder which can cause psychosis resulting in hallucinations and delusional thoughts), anxiety disorder, type 2 diabetes mellitus , Chronic Kidney Disease (gradual loss of kidney function which can cause dangerous levels of fluid, electrolytes and wastes to build up in your body), Major Depressive Disorder (persistent feeling of sadness and loss of interest), high blood pressure, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and unspecified psychosis (psychosis not due to a substance or physiological condition). Review of Resident #53's quarterly MDS assessment, dated 08/14/2022, revealed Resident #53 had a BIMS score of zero to indicating severe cognitive impairment. Resident #53 did not have any behaviors noted on the assessment. Resident #53 had active diagnoses of anxiety disorder, psychotic disorder and schizophrenia. Resident #53 was noted to receive anti-psychotic medications seven days per week and none on an as needed basis. Review of Resident #53's care plan, dated 09/27/2022, revealed Resident #53 had the potential to be physically and verbally aggressive related to dementia with behaviors noted: 03/19/2022 - aggressive behavior with staff and verbal aggressive behavior with other residents 05/29/2022 - physical aggression noted 06/06/2022 - physical and verbal aggression 09/25/2022 - hitting at another resident, received three scratches on his face Goals included the resident will demonstrate effective coping skills through the review date and the resident will not harm self or others through the review date. Interventions included: o3/19/2022- When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Have psychological services assess and treat-adjust medication. o 5/29/22 Medication Review o 9/25/22 Staff to monitor resident when he approaches another resident and gets in their personal space o Administer ABH Gel as needed for aggressive behaviors o Administer medications as ordered. Monitor/document for side effects and effectiveness. o Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 03/24/2021 o Assess and address for contributing sensory deficits Date Initiated: 03/24/2021 o Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 03/24/2021 o Be Cognizant when resident invades another resident's personal space Date Initiated: 09/26/2022 o COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 03/24/2021 o Monitor q shift Document observed behavior and attempted interventions in behavior log. oMonitor/document/report PRN any signs and symptoms of resident posing danger to self and others. Date Initiated: 03/24/2021 o Psychiatric/Psychogeriatric consult as indicated. Review of Resident #53's physician orders, dated 03/20/2022, revealed Resident #53 was prescribed Seroquel 25 mg one time a day for paranoid schizophrenia. Resident #53 was prescribed Seroquel 25 mg at bedtime for psychosis. Resident #53 was prescribed Depakote ER tablet Extended Release 24-hour 250 MG with instructions to give one tablet at bedtime for anxiety. Resident #53 was prescribed Donepezil HCl Tablet 10 MG with instructions to give one tablet by mouth at bedtime for memory care. An observation on 09/27/2022 at 10:47 AM revealed Resident #53 sat in his wheelchair and banged on the exit door of the locked unit. CNA L attempted to redirect him. Resident #53 was heard to calling CNA L a bitch. Overheard CNA L say to Resident #53, the ACT DIR would be there soon to take him outside. Resident #53 then wheeled himself down the hallway and started banging on the side exit door to the courtyard. CNA L attempted to redirect to an activity on the table. Resident #53 then wheeled himself down the hallway and started banging on the rear exit door. RN M said to Resident #53 you are going to break a window if you keep hitting it. Resident #53 opened and closed the fire extinguisher door on the wall and attempted to break the glass in it. CNA L redirected him down the hallway. Resident #53 wheeled himself back up the hallway towards the common area where six residents were sitting. Resident #53 removed a box of gloves from the side rail of the hallway and threw it down the hallway. CNA L attempted to stop Resident #53 and he swatted at her to try to hit her. Resident #53 said I am going to beat the shit out of you. He then grabbed the wrist BP cuff off the nurse medication cart and attempted to throw it when CNA N took it away from him. In an interview on 09/27/2022 at 10:54 AM, CNA N stated Resident #53's behavior was normal for him probably four out of seven days per week for several months at that time . She stated Resident #53 had a history of being combative with staff and residents. She said he just wanted out of the locked unit. She stated they tried to give him space and let him calm down. She said managing Resident #53's behavior was challenging at times. She said there were 23 residents on the locked unit with two CNA's and one charge nurse. She said at 2:00 PM, the ACT DIR came to help with residents and would take Resident #53 outside. In an observation on 09/27/2022 at 11:00 AM, Resident #53 banged on the front door and rattled the door handles on the locked unit multiple times. In an observation on 09/27/2022 at 11:06 AM, Resident #53 hit the side exit door multiple times and he attempted to hit CNA N. In an observation on 09/27/2022 at 12:36 PM, Resident #53 was hitting the front exit door of the locked unit and yelling. Resident #23 yelled at Resident #53 to stop hitting the door and then Resident #23 took the lid off his water cup and dumped the water on Resident #53. RN M redirected Resident #23 as CNA L and CNA N were feeding two other residents in the dining area. Resident #53 then wheeled himself to the side exit door in the dining area and started rattling the door handle and hitting the door. At 12:41 PM, Resident #17 stood up, went to Resident #53 and began yelling at him. RN M was in between them, separating them and made Resident #17 sit back down. Resident #17 and Resident #53 were yelling curse words at each other as eight residents continued to eat in the dining area. Resident #17 sat back down and began eating again. In an observation and interview on 09/27/2022 at 12:52 PM, RN M walked to the medication cart and said Resident #53 did not have any PRN medications for agitation. He picked up his phone to call the physician and as he turned back to the dining area, Resident #17 stood up from his table with his plate and smashed it on the back of Resident #53's head. Both CNA's that were feeding residents at front of dining room and nurse responded and separated the residents. Resident #53 complained of head pain and was taken to his room for assessment. Resident #17 sat back down at his table and was quiet. ADON P came in the locked unit and assisted with Resident #53. Resident #77 was upset and crying. In an observation on 09/27/2022 at 12:58 PM, RN M gave Resident #53 two Tylenol and paged his physician who said to send Resident #53 to the ER for evaluation for CT scan of head. Resident #53 had a large hematoma on the back, left side of his head. In an interview on 09/27/2022 at 1:05 PM, the DON stated Resident #17 had no history of aggressive behaviors with staff or residents. She was shocked Resident #17 would hit Resident #53 with his plate. Review of Resident #53's health status note dated 09/25/2022, written by LVN J, revealed Note text: this writer witnessed this resident starting to talk to another resident and the resident asked him to leave her alone, then this resident (Resident #53) started throwing punches at this other resident. head to toe assessment done by the nurse, noted three scratches marks on this resident (Resident #53) face, no open areas, no bleeding noted. VS WNL. MD notified, DON and family notified. Review of Resident #53's Investigation Follow-up, dated 09/25/2022, revealed primary nurse witnessed resident starting to talk to another resident and the resident asked him to leave her alone, then then this resident (Resident #53) started throwing punches at another resident, resident never hit the other resident. Residents separated and re-directed. Resident #53 was noted to have three scratch marks. Recommendations/interventions noted were separate residents, continue to re-direct. Psych services to eval/treat and medication review management. Continue to monitor every 15 minutes. In a follow-up interview on 09/27/2022 at 3:50 PM, CNA L stated Resident #53's behavior had been worse since July 2022. She said he used to be nice to her and CNA N, they were his favorites, but now he tried to hit them and cursed at them routinely. She said they redirected him or tried to engage him in activities. She said once he was agitated, it was difficult to redirect him. She said she was not working on 09/25/2022, when Resident #53 started to punch Resident #97 and Resident #97 scratched him on the face . She said when she returned to work today she was not told of any new interventions put into place for Resident #53 to prevent him from upsetting or attacking other residents. In a follow-up interview on 09/27/2022 at 3:55 PM, RN M stated he was not aware of any new behavioral interventions the facility put into place for Resident #53 after the incident on 09/25/2022. He stated there were no medication changes made for Resident #53 and did not know whether psychological services had been notified of his escalating behavior. He stated he did not normally work on the locked unit and was not as familiar with Resident #53. In a follow-up interview on 09/27/2022 at 4:05 PM, CNA N stated she was not aware of any additional interventions put into place for Resident #53 following the incident on 09/25/2022. She stated they tried to redirect and distract him when he became agitated. In a follow-up interview on 09/27/2022 at 4:38 PM, the DON stated Resident #53 was at the ER pending evaluation and they had no update regarding his head injury. She stated Resident #17 was put on one-on-one monitoring pending an evaluation by psychological services. She stated normally Resident #53 was easy to redirect and distract. She stated they would call his family who would speak with him on the phone and calm him down. She stated, in the past, Resident #53 had ABH gel ordered for when he became combative and unable to be calmed down. She stated his MD gave a one-time order for it on 09/26/2022 to be used for treatment of the scratches Resident #53 had from the altercation on 09/25/2022. She stated the other resident involved, was not injured. She stated the facility put additional interventions in place following the incident on 09/25/2022, including notifying psychological services to evaluate his medications. When asked why Resident #53 was not put one-on-one monitoring at that time pending the evaluation, she said she did not know and would find out. She stated the staff were to monitor him more closely and especially when interacting with other residents. In a follow-up interview on 09/28/2022 at 7:50 AM, the DON stated Resident #53 returned from the ER last night had no injury to his head besides the bruise. She said his CT scan was negative for any other injury. She stated Resident #53 was also on one-on-one monitoring since his return from the ER until he could be seen by psychological services. An observation on 09/28/2022 at 9:24 AM revealed Resident #53 had a staff member with him at all times and documentation every 15 minutes. Resident #53 sat in his wheelchair with his head on a pillow on the table sleeping beside staff members. In an interview on 09/28/2022 at 9:30 AM, LVN J stated she was the routine nurse for the locked unit and knew Resident #53 well and how to deal with his behaviors. She stated staff unknown to Resident #53 or agency nurses did not know how to deal with him. She stated she was his nurse on 09/25/2022 when he was agitated and upset. She said Resident #53 started throwing punches at Resident #97 who then scratched Resident #53 on the face. She said they were treating the scratches daily with normal saline. She said she and the aides started monitoring him more closely and did not leave him unattended when he was around other residents. She said Resident #53 was not put on one on ones and was not sure why since the facility immediately put Resident #17 on one on ones when he attacked Resident #53. She stated Resident #17 and Resident #97 were not typically aggressive or combative towards staff or residents, but seemed to be provoked or agitated by Resident #53's behavior. She stated one issue that increases his behavior was when he refused his medications. She stated she knew how to get him to take his medications and Resident #53 was doing well today. She said the activity aide would come at 2:00 PM, during the week, and that helped a lot with Resident #53 because she took him outside and he liked that. She stated besides watching Resident #53 closely, she was not aware of any additional interventions put into place by the facility that may have prevented the incident yesterday 09/27/2022. In a follow-up interview on 09/28/2022 at 1:48 PM, the DON stated Resident #53 was not put on one on ones after the 09/25/2022 incident and the facility's intervention was to refer to psychological services for a non-routine evaluation of his medications. In an interview on 09/29/2022 at 10:25 AM, NP R, mental health nurse practitioner for Resident #53, stated she did not feel any medication changes were necessary at this time. She stated she restarted the PRN ABH gel for agitation or refusal of care for 14 days and would reevaluate in 14 days, the need to continue the order. She stated she ordered for one on ones to continue until her visit next week for Resident #53 and to notify of her of any increased behaviors. In a follow-up interview on 09/29/2022 at 12:15 PM, the DON stated Resident #53 would remain on one on ones until behaviors were gone. She said after his behaviors were decreased, there would always be additional staff available, like the two ADON's and her to assist if Resident #53 was having a bad day. She said on the weekend, the house manager RN would assist if needed if Resident #53 had increased behaviors. She stated they would in-service the staff to notify of the need for additional assistance and updated Resident #53's care plan. She stated if they felt Resident #53 required additional PRN orders for the ABH gel, they would notify the physician. Review of Resident #53 Psychological progress note, written by a licensed psychologist dated 09/24/2022, revealed Resident #53 was seen weekly and was not displaying any risk factors including substance abuse, suicidal/self-injury, sexual acting out, homicidal or aggressive behavior. The psychologist documented Resident #53's target symptoms were anxiety, depression, and uncooperativeness which was noted as very mild. The plan for the next session was noted to be will explore reason for increased aggression and frustration. Review of Resident #53 Psychiatric Subsequent Assessment, dated 08/08/2022, written by NP R revealed the medical necessity for the visit was patient seen at staff request. Reason: Increased exit seeking behavior. It was noted that nursing staff reported patient was at the exit door multiple times but did not push on the door. No changes were made to Resident #53's medication regimen. Review of Resident #53's Health Status note, dated 09/26/2022 at 4:25 AM, revealed Resident #53 was alert and oriented with confusion, restless, attempting to get out from exit door. Agitated when redirect. ABH GELL applied to hands and shoulder with effective result. Three scratches to face is cleaned with normal saline. Review of Resident #53's Health Status note, dated 09/26/2022 at 11:08 AM, revealed Resident #53 was on follow up for altercation with another resident. Resident is alert, not violent to other residents nursing staff closely monitoring resident. Review of Resident #53's Health Status note, dated 09/27/2022 at 11:01 AM, revealed Resident #53 was noted to have Behavior: Resident is seeking exit, nursing staff closely monitoring and redirecting. Nonpharmacological interventions: Calm approach to redirect, offered snack but refused. PRN medications: NA Results: Helped a little bit. Review of Resident-to-Resident Altercations policy dated December 2016 revealed facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors or to the staff. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation . f. make any necessary changes in the care plan approaches to any or all of the involved individuals g. Document in the resident's clinical record all interventions and their effectiveness.

Based on observation, interview, and record review the facility failed to assure residents received and consumed foods in the appropriate form as prescribed by a physician for 5 (Residents #71, #45, #36, #39, and #3) of 5 residents reviewed for altered diet textures. AD F, CNA C, CNA D, and CNA E served regular textured popcorn to Residents #71, #45, #36, #39, and #3 who were on mechanical soft diets. Resident #45 and #71 began to cough as they ate the popcorn. This failure placed residents who required mechanically altered diets at risk for aspiration (food or liquid entering the airway), aspiration pneumonia, choking, hospitalization , and death. On 06/29/21 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/01/21, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. Findings Included: Record review of Resident #45's Face Sheet dated 06/30/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: dementia, [CONDITION(S)], hypertension, anxiety disorder, heart disease, weakness, need for assistance with personal care, GERD, and oropharyngeal phase dysphagia. Record review of Resident#45's Physician order summary report dated 06/30/21 revealed an order start date 10/19/20 for Regular diet Dysphagia Advanced texture, Regular consistency, with no end date. Record review of Resident #45's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 4 indicating severely impaired cognition. The MDS also indicated Resident #45 needed supervision and set-up assistance for eating. Review of Resident #45's Care Plan, undated, revealed in part: Problem . I have potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #45's Speech Therapy Plan of Care dated 01/19/21 reflected the following: Patient is an [AGE] year old male long-term resident at this facility who was referred/screened per clinician to ST services . Skilled therapy is necessary to improve oropharyngeal dysphagia . Functional Deficits .Swallowing, oral phase .Swallowing, pharyngeal phase . seen at bedside .missing dentition on top and is edentulous on bottom . continue Dysphagia Advanced Diet . Record review of Resident #71's Face Sheet dated 06/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: dementia, lack of coordination, need for assistance with personal care, anormal weight loss, weakness, cognitive communication deficit, Alzheimer's, GERD, and oropharyngeal phase dysphagia. Record review of Resident#71's Physician order summary report dated 06/30/21 revealed an order start date 07/30/20 for Regular diet Dysphagia Advanced texture, Regular consistency, with no end date. Record review of Resident #71 Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 2 indicating severely impaired cognition. The MDS also indicated Resident #71 needed extensive assistance with one staff for eating. Review of Resident #71's Care Plan, undated, revealed in part: Problem . I have an ADL Self-Care Performance Deficit muscle weakness . Eating: I require supervision/set-up to maintain independence/safety . Problem . I have potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #71's Speech Therapy Plan of Care dated 11/30/20 reflected the following: Patient is an [AGE] year old female long-term resident at this facility who was referred/screened per clinician to ST services . Skilled therapy is necessary to improve oropharyngeal dysphagia . Functional Deficits .Swallowing, oral phase .Swallowing, pharyngeal phase . facility staff will demonstrate comprehension and functional utilization of diet modifications, aspiration precautions, and feeding assistance recommendations as indicated . Dysphagia/ Aspiration Precautions include: mechanical soft diet, staff to prompt for adequate intake. Feeding assistance as indicated . Record review of Resident #36's Face Sheet dated 06/30/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's, muscle weakness, [CONDITION(S)], hypertension, need for assistance with personal care, lack of coordination, and dysphagia (oropharyngeal phase). Record review of Resident#36's Physician order summary report dated 06/30/21 revealed an order start date 02/04/21 for Regular diet Dysphagia Advanced texture, Regular consistency, for Aspiration Precautions. Monitor for adequate intake, with no end date. Record review of Resident #36 Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 0 indicating severely impaired cognition. The MDS also indicated Resident #36 needed supervision and set up assistance for eating. Review of Resident #36's Care Plan, undated, revealed in part: Problem . I have an ADL Self-Care Performance Deficit [related to diagnosis] dementia . I require supervision with 1 staff participation to eat . Problem . [Resident #36] has a potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #36's Speech Therapy Plan of Care dated 01/19/21 reflected the following: Patient is an [AGE] year old female long-term resident at this facility who was referred/screened per clinician to ST services due to significant weight loss . Skilled therapy is necessary to improve oropharyngeal dysphagia .Functional Deficits .Swallowing, oral phase .Swallowing, pharyngeal phase .Cognition, Mental Status . confused . following recommendations: mech[anically] soft diet . Record review of Resident #39's Face Sheet dated 06/30/21 revealed he was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: dementia, diabetes mellitus, need for assistance with personal care, heart failure, muscle weakness, [CONDITION(S)] disease, and oropharyngeal phase dysphagia. Record review of Resident#39 's Physician order summary report dated 06/30/21 revealed an order start date 06/10/21 for Consistent Carbohydrate (CCD) diet Dysphagia Advanced texture, Regular consistency, with no end date. Record review of Resident #39's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 3 indicating severely impaired cognition. The MDS also indicated Resident #39 needed supervision and set-up assistance for eating. Review of Resident #39's Care Plan, undated, revealed in part: Problem . potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #39's Speech Therapy Plan of Care dated 08/07/20 reflected the following: .referred to ST services for assessment of swallowing and cognitive-communication strategies . Precautions: fall risk, dysphagia, sundowning, mechanical soft . seen at bedside . Reduced strength and coordination of lingual muscle . Recommend downgrade to mechanical soft . Record review of Resident #3's Face Sheet dated 06/30/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's, metabolic [CONDITION(S)], [CONDITION(S)], hypertension, need for assistance with personal care, weakness, dementia, and oropharyngeal phase dysphagia. Record review of Resident#3's Physician order summary report dated 06/30/21 revealed an order start date 01/06/21 for Regular diet Dysphagia Advanced texture, Regular consistency, Frozen nutritional treat with meals for Aspiration Precautions. Check for pocketing, with no end date. Record review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not documented. The MDS also indicated Resident #3 needed supervision and set-up assistance for eating. Review of Resident #3's Care Plan, undated, revealed in part: Problem . ADL self-care performance . Eating: The resident can: feed self [with] supervision The resident requires limited assistance by 1 staff to eat . Problem .potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #3's Speech Therapy Plan of Care dated 01/06/21 reflected the following: Patient is an [AGE] year old male long-term resident at this facility who was referred/screened per clinician to ST services . Functional Deficits .Swallowing, oral phase .Swallowing, pharyngeal phase . demonstrates ability to safely swallow Mechanical soft/ Dysphagia Advanced, small pieces diet using compensatory strategies from trained staff . Facility staff and familial caretakers will demonstrate comprehension and functional utilization of aspiration precautions, diet modifications, and prompting/assistance recommendations in order to facilitate safe and efficient nutrition .] Observation at the memory care unit on 06/29/21 at 1:45 PM revealed Residents #45, #36, #39, and #3 were provided popcorn in disposable cups. Resident #71 received a plateful of popcorn while sitting at a dining room table. AD F, CNA C, CNA D, and CNA E handed the popcorn to the residents. While eating the popcorn, Resident #71, Resident # 45, and Resident #35 began to cough. Resident #35's face became red and produced a wet sounding cough. Resident #71 and #45 produced a dry cough. The residents alternated coughing for approximately 2 minutes. Staff present during the coughing included AD F, CNA C, CNA D, CNA E, and LVN A. None of the staff intervened while the residents were coughing, and the residents continued to eat popcorn. In an interview on 06/29/21 at 2:45 PM, SLP G stated a dysphagia advanced diet was a mechanical soft texture. She said the meats would be chopped, sides would include soft foods, and foods would be cooked a little longer to be soft. When asked the reason a resident would be ordered a dysphagia advanced diet, SLP stated it would be ordered for someone if they had no teeth or bad dentition and were not able to chew up the regular or if they had oral or pharyngeal dysphagia to reduce the risk of food going into their lungs and aspirate. When asked if a resident on an advanced dysphagia diet could eat popcorn, SLP stated no because the resident could aspirate and choke. SLP said signs of aspiration included coughing, turning red, nose starts to run. If you had a pulse ox, O2 sats may drop. When asked what she would do if she were notified a resident on a dysphagia advanced diet ate popcorn, SLP said, I would assess [the resident] and educate the staff on appropriate diets. In an interview on 06/29/21 at 3:25 PM CNA C stated that a resident ordered a mechanical soft diet has meats that are chopped. She stated a resident may be placed on a mechanical soft diet if they had difficulty swallowing or issues with their teeth. CNA C said the popcorn activity is occurs once or twice a week. She said popcorn was a choking hazard for residents and CNAs watch them while they're eating it. When asked if she was taught that popcorn was a choking hazard, she said, I've heard that at another facility. CNA C stated she was never told residents ordered a mechanical soft diet cannot eat popcorn. CNA C further stated, It's normal for [residents] to have popcorn, that's why we keep [residents] on our observation. CNA C denied hearing Resident #71 and Resident #45 coughing. In an interview on 06/29/21 at 3:35 PM CNA D stated that a resident ordered a mechanical soft diet has meats that are ground or chopped up, that way they can chew it and get it down. When asked the reason a resident would be ordered a mechanical soft diet, CNA D state it would be for a resident who had issues with swallowing or issues with their teeth or chewing. When asked how often residents received popcorn with activities, CNA D said one or two times a week. She further stated that residents ordered a pureed diet are given pudding or applesauce, but residents ordered a mechanical soft diet can eat popcorn. CNA D further stated, We watch [the residents] because anybody can choke off popcorn, even if they eat regular food. I've never been told that anyone on mechanical soft diet shouldn't have popcorn. In an interview on 06/29/21 at 3:46 PM AD F stated residents receive popcorn as an activity once a week or once every two weeks. When asked who receives food alternatives to popcorn, AD F said, most of them can have it, the only ones that can't have [popcorn] are the ones that are on pureed. When asked if residents ordered a mechanical soft diet can have popcorn, AD F stated, I would think so, as long as they're not eating the seeds. AD F stated no one had told her residents ordered a mechanical soft diet cannot have popcorn. AD F stated she did not hear any of the residents coughing while eating popcorn. In an interview on 06/29/21 at 3:52 PM, LVN A said residents receive popcorn once a week, and there was pudding or applesauce available for residents ordered a pureed diet. LVN A stated she did not hear any of the residents cough while eating popcorn but that some residents cough all the time. When asked if residents ordered a mechanical soft diet should eat popcorn, LVN A stated, They probably shouldn't have it, but that's why I am there watching them. LVN stated she had not been told residents ordered a mechanical soft cannot have popcorn. In an interview on 06/29/21 at 4:03 PM, the DON said a dysphagia advanced diet was a mechanical soft diet. She further stated a resident would be ordered if they had dysphagia, and if a MBSS documented that's what [the resident] can tolerate safely. When asked what would happen if a resident were to receive food that was not appropriate for their ordered diet texture, the DON said the resident could aspirate or choke, up to death. When asked if residents ordered a mechanical soft diet could eat popcorn, the DON said, I don't want them to have popcorn, I don't feel comfortable with them having it. The DON further stated that a resident ordered a mechanical soft diet should not have popcorn because they could choke or aspirate. When asked what she would expect a nurse to do if a resident ordered a mechanical soft diet was coughing while eating, the DON stated the nurse should get up and see why [the resident was] coughing. Review of the facility's June 2021 activity calendar reflect Movie and Popcorn Social, were scheduled for the following dates: 06/02/21, 06/03/21, 06/10/21, 06/17/21, 06/22/21, and 06/24/21. Review of the facility policy titled Diet Nutrition Care Manual, dated 2019, reflected in part: Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet This diet is used for individuals with mild oral and/or pharyngeal dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. Food should be prepared according to individual tolerance to the food. Any foods that are very hard, sticky, chewy, or crunchy should be avoided . Foods to Avoid . any dry, tough or crusty bread . crackers . toast . dry crunchy cereals . popcorn .chips . Review of Optimizing Texture Modified Foods for Oro-pharyngeal Dysphagia: A Difficult but Possible Target?, dated 2018 and accessed on 07/08/21 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 51/, reflected the following: Dysphagia is a swallowing disorder characterized by the difficulty in transferring solid foods and/or liquids from the oral cavity to the stomach, impairing autonomous, and safe oral feeding. The main problems deriving from dysphagia are tracheo-[MEDICATION(S)] aspiration, aspiration pneumonia, malnutrition and dehydration . Oropharyngeal dysphagia (OD) is a dysfunction of the digestive system, consisting of a difficulty in swallowing which affects the proper transit of the bolus in the upper digestive tract. The main complications of dysphagia are tracheo-[MEDICATION(S)] aspiration (food transit in the airways with choking), aspiration pneumonia (pneumonia caused by food in the lungs), malnutrition and dehydration . Dysphagic patients fail to control food flow, which is fast and turbulent through the oropharynx, with the risk of misdirection through the respiratory tract . Review of Dysphagia in the elderly: management and nutritional considerations, dated 2012 and accessed on 07/08/21 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/, reflected the following: Dysphagia is a prevalent difficulty among aging adults. Though increasing age facilitates subtle physiologic changes in swallow function, age-related diseases are significant factors in the presence and severity of dysphagia. Among elderly diseases and health complications, stroke and dementia reflect high rates of dysphagia. In both conditions, dysphagia is associated with nutritional deficits and increased risk of pneumonia . Dysphagia is a common symptom in dementia. It has been estimated that up to 45% of patients institutionalized with dementia have some degree of swallowing difficulty.39 Different clinical presentations of dementia will result in different swallowing or feeding impairments.40-43 Most commonly, patients with dementia demonstrate a slowing of the swallowing process.14 Slowed swallow processes may increase time taken to finish a meal and subsequently increase the risk for poor nutritional status.14 Furthermore, patients with dementia often have difficulties self-feeding. These difficulties may relate to cognitive impairment, motor deficits such as weakness or [CONDITION(S)], loss of appetite, and/or food avoidance. As a result, patients with dementia may experience weight loss and increased dependency for feeding.14 Subsequently, increased feeding dependency may lead to other dysphagia-related health problems, including pneumonia.14 Weight loss can reflect decreased nutritional status which increases the patient's risk of opportunistic infections such as pneumonia.44-46 Pneumonia is a common cause of mortality in patients with dementia.47 Thus, dementia, dysphagia, and related feeding impairments can lead to nutritional deficits which in turn contribute to pneumonia and mortality. Among elderly patients in particular, the presence of dementia is associated with higher hospital admission rates and overall higher mortality . Diet modifications: modification of foods/liquids. Modifying the consistency of solid food and/or liquid is a mainstay of compensatory intervention for patients with dysphagia.37 The goal of diet modification is to improve the safety and/or ease of oral consumption and thus maintain safe and adequate oral intake of food/liquid. However, low acceptability and resulting poor adherence with modified foods/liquids can contribute to increased risk of inadequate nutrition in elderly patients with dysphagia . On 06/29/21 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/01/21, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 06/29/21 at 8:11 PM. The facility Administrator was notified on 06/39/21 at 8:08 PM that there was Immediate Jeopardy (IJ) was identified due to the above failures. The Plan of Removal (POR) was accepted on 07/01/21 at 3:57 PM and included the following: 1. On 06/29/2021, upon discovery of concern: Station 1 Assistant Director of Nursing, [ADON B] and MDS coordinator, [MDS Coordinator], assessed the 6 residents identified (Resident #71, Resident #45, Resident #36, Resident #39, Resident #25, Resident #3] as receiving popcorn to determine ill toward effects from consumption and for signs and symptoms of aspiration; there were no negative findings for any of the identified 6 residents. Physician, and family were notified at 5:30pm by [ADON B], ADON and [MDS Coordinator], MDS. The Physician gave no new orders for any of the 6 residents. 2. On 06/29/2021: Station 2 Assistant Director of Nursing, [ADON R], added an order to Nurses' MAR for q shift monitoring of signs and symptoms of aspiration for a minimum period of 48 hours for the 6 identified residents, this was initiated at 10:11pm and will end at 7/1/2021 at 10:11pm. 3. Regional Registered Dietician, reviewed other residents within the facility for diet order types and identified other facility residents at risk to include residents with Advanced Dysphagia diets (mech soft). As of 6/29/2021, there are 46 out of 113 residents identified. 4. DON, and ADONs [ADON B] and [ADON R] in-serviced incoming and subsequent nursing team members, including Nurses and Nurse Aides/Med Aides: verifying meal orders prior to serving any meal/snack. At risk residents will be monitored while consuming any meals/snacks; monitoring will be in the form of observation while in dining areas and/or walking rounds if resident remains in room. Only diet appropriate snacks will be served to residents from facility staff. These departments will be responsible for consulting diet orders for consuming residents. 5. On 6/29/2021: DON, and ADONs [ADON B and ADON R] and MDS Coordinator provided a diet listing report that was posted at the nurse's station to identify those residents for communication to nurses, activities and nurse aides. Completed 6/29/2021. Staff informed of this addition during current and subsequent in services. 6. On Wednesday 6/30/2021, Licensed Speech Therapist [SLP BBB] is scheduled to further assess the identified 6 residents and will evaluate diet types for appropriateness. Anticipated completion date 6/30/2021. 7. On 6/29/2021, Registered Dietician cross referenced diets against Meal Tracker tray tickets with physician orders for accuracy and diet type and informed team of any variance. Completed 6/30/2021. 8. On 6/29/2021: Education regarding verifying diet orders and the addition of the diet listing report have been arranged via in-service to be given by DON, ADONs [ADON B and ADON R] and Certified Dietary Manager [DM] all staff and nursing agency beginning with those present in building on 6/29/21 at approximately 9pm. Any staff member or nursing agency not in attendance will be required to receive education prior to the start of their next scheduled shift. This will be followed up by a competency test. 9. On 6/30/2021; All staff and nursing agency will be educated with a separate in-service re: signs/symptoms of Aspiration. Education will be provided by DON, ADONs [ADON B and ADON R] and MDS Coordinator. Any team members not in attendance will be required to receive education prior to the start of their next scheduled shift. Lists from each department have been cross referenced with team members receiving education to verify completion of education. Anticipated completion date: 07/01/2021/ 10. On 6/29/2021: List of appropriate snack options for residents on Dysphagia Diets available to any team members administering snacks; list is located in same binder as resident's diet orders. Anticipated completion date: 06/30/2021. This will be followed up with a competency test. Monitoring of the plan of removal by HHSC Surveyors revealed: In an interview on 06/30/21 at 10:17 AM, the Regional Nurse stated that 6 residents (Residents #71, #45, #36, #65, #39, and #3) that were identified as having received the inappropriate diet texture were assessed by ADON B and the MDS Coordinator. She stated the assessment included lung sound assessment and vital sign assessment. She also stated that all the residents in the memory care unit would be assessed for signs and symptoms of aspiration. and assessed. She further stated the regional SLP arrived at 7:15 AM and was working on doing speech evals but started off on the memory care unit. An observation and interview on 07/01/21 at 12:49 PM revealed the MDS coordinator stated she received training on how to monitor residents, verification of knowing signs and symptoms of aspiration. Ensuring the safety of our residents during mealtime. When asked if there were any place nurses could review the information provided in the in-services, the MDS Coordinator stated there were posters in the nursing stations and it was also located in the diet book at the nurses' station. An observation of the nursing station verified the posters and diet book were present with specific diet information. The MDS Coordination stated that residents ordered a dysphagia advanced diet were not to receive popcorn. When asked the signs or symptoms of aspiration were coughing, nasal drip, runny eyes, grabbing throat, and choking. When asked what intervention would be implemented if the signs of aspiration or choking were noted while a resident was eating, MDS Coordinator said, First, remove the food, sit them up, assess and ensure there is no blockage. Check the color of their skin and lips. Watch their respirations. Listen to lung sounds for wheezing, check for fever, and check O2. If there are no negative findings, I would call the doctor to notify them of the coughing episode and of my assessment findings. Then the nurses would input a nurse's order to assess the resident for 48 hours including auscultation of lung sounds and vital signs. If I assess the resident and they are showing signs of choking, not breathing, turning blue, I would immediately call 911 and then call the doctor. In an interview on 07/01/21 at 1:01 PM, LVN L stated she had received training on the kinds of food that they can and can't have. We have a book with the different diets at every nurses' station. When asked, LVN L sad residents ordered a dysphagia advanced diet were not to receive popcorn. LVN L stated that nurses make sure the meal ticket is the correct diet and correct texture. LVN L also said nurses would confirm resident snacks are the correct diet texture. When asked what would happen if a resident received food not appropriate for their ordered diet textures, she said residents could aspirate or choke. LVN L said the signs and symptoms of aspiration included: change in voice, drooling, coughing, fatigue, and secretions. LVN L said interventions for aspiration or choking included: making sure there is nothing in the resident's mouth, call the doctor and make them aware, check residents respirations, listen to lung sounds, and assess vital signs. She stated when she would also continue to monitor and pass it on to the oncoming nurse in report. In an interview on 07/01/21 at 1:12 PM, CNA ZZ said she was an agency staff. CNA ZZ said she received an in-service and a test on altered diet and what foods items they can eat. She stated residents on a dysphagia advanced diet cannot eat popcorn. When asked where she would find what diet a resident was ordered, CNA ZZ stated she would look on the meal tickets or go to the charge nurse to ask about the diet. CNA ZZ said the signs of aspiration were coughing, choking, drooling, and holding their neck and if observed she would remove the object from their mouth and do the [MEDICATION(S)] if they were choking. She stated other interventions included put them in an upright position and report it to the nurse. Do not let [the resident] continue eating until the nurse approved. In an interview on 07/01/21 at 1:18 PM, CNA QQ said she received and in-service about diets. When asked the content of the training, CNA QQ said people on pureed or mechanical food, what they can and can't eat like grapes, peanuts. Mechanical people cannot have popcorn and can't eat peanuts or M&Ms. If I don't know the diet, I can go to the nurse or in the dining room I will look at the book for diets. CNA QQ further stated the nurses check the meals and snacks to make sure they are the correct consistency. When asked what would happen if a resident received food that was not the correct texture, CNA QQ said, They could aspirate or choke. CNA QQ said signs of aspiration included: nose running, eyes running, and coughing. She stated if she noted these signs while a resident was eating, she would stop the person from eating and call the nurse. In an interview on 07/01/21 at 1:24 PM, MA AAA said she received an in-service about people that was having difficulty swallowing and what is acceptable for them to take according to their diet. Mechanical soft can't have popcorn because they could choke. Look at their diet before you give [residents] anything. MA AAA said signs of aspiration were runny nose, watery eyes, and coughing. She stated if those signs were observed in a resident she would Stop and check and see what's wrong with them, tell the nurse, and stop them from eating. In an interview on 07/01/21 at 1:28 PM, CNA D she received and in-service on diets types and the types of foods a person can have with a specific diet. Mech soft no popcorn. Could choke or aspirate. S/S asp- runny nose, runny eyes, coughing, choking. If heard coughing look at them make sure they are breathing, notify the nurse. Stop them from eating. Nurse checks meals and snacks to ensure accuracy. In an interview and observation on 07/01/21 at 1:30 PM, LVN A stated she received an in-service about making sure that [residents] are getting the right diet and right liquids and fluids to drink. There's a book at the nurses' desk to review diets if needed. LVN A stated that residents on a dysphagia advanced diets cannot popcorn because they could choke or aspirate. LVN A stated the signs of aspiration included: eyes runny, nose running, clearing their throat after every bite, coughing. LVN A stated interventions if a resident was coughing while eating included the nurse being altered, ensuring their airway is clear, and listen to lung sounds. Observation revealed there was a book at the memory care nurses' desk which included a page explaining the diet textures and examples of acceptable snacks for each. In an interview on 07/01/21 at 1:48 PM AD F said she received an in-service on the difference on what mechanical soft diets can have and what they can't have. No popcorn, nuts, figs, granola. I keep that information in my activities binder for reference and that goes with me on activities. Alternative snacks will include pudding and applesauce. When asked what could happen if a resident received food that was not appropriate for their diet, AD F said a resident could choke and aspirate and if I see any of that I would get the nurse immediately. Stop [the resident] from eating. The nurse would check any food given during food activities. In an interview on 07/01/21 [TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for five (Residents #1, #25, #33, #68 and #99) of five residents reviewed for elopements. 1. Resident #99 eloped from the facility in June 2020 and was found by facility staff in the back parking lot. 2. Resident #68 eloped from the facility in February 2021 and was found by a community member in the middle of the night and returned by the police. 3. Resident #25 eloped from the facility twice in May 2021, once during the night, and was found by a community member and returned by the police. 4. Resident #33 eloped from the facility in May 2021 and was found by staff in the behind the facility. 5. Resident #1 eloped from the facility in May 2021 and was found in the front of the facility in the parking lot by facility staff. 6. The facility failed to ensure staff were trained and aware of the exterior exit door alarms and wander guard alarm activation/deactivation protocols. 7. The facility staff were observed on multiple occasions propping the exterior exit doors open, including the front entry wander guard secured door, causing the system to not alarm if a resident were to attempt to elope. An Immediate Jeopardy was identified on 06/30/21 at 9:15 AM. While the Immediate Jeopardy was removed on 07/02/21, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could affect residents with exit-seeking behaviors by placing them at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme heat exposure. Findings included: 1. Review of Resident #25's annual MDS assessment dated [DATE] revealed she was an [AGE] year old female admitted to the facility on [DATE]. Her active diagnoses included dementia, diabetes, heart failure and hypertension. Resident #25's BIMS score was 04, which indicated severe cognitive impairment. She had symptoms of [CONDITION(S)], which included continuous inattention that did not fluctuate, no [CONDITION(S)] and no wandering behavior. She used a wheelchair for mobility, had range of motion impairments on both sides of her upper and lower body, and required extensive physical assistance of one staff to ambulate in her wheelchair. Resident #25 had impaired vision and wore glasses. Review of Resident #25' care plan reflected identified a problem Elopement Risk initiated on 02/12/2021 which reflected, Resident will not elope from the facility. Initial interventions on 02/12/21 included to assess the resident for risk of elopement, initiate a wander guard for the resident, check placement every shift and function every month. A revision to the care plan was made on 05/12/21 to place Resident #25 in the secured unit for safety. Review of Resident #25's elopement incident report dated 05/10/21 at 9:40 pm revealed she was found by RN N outside on the street and was brought back inside using a wheelchair. An assessment was done with no injuries noted. Predisposed physiological/situational factors indicated she was confused, had an impaired memory and was a wanderer. Review of Resident #25's second elopement incident report dated 05/17/21 at 11:10 pm revealed she was Brought back into the facility from outside safely. No time was documented on when she was found, where she was found and who found her. No injuries were observed by ADON B, who completed the report. Predisposing physiological/situation factors indicated she was confused, had impaired memory, gait imbalance, ambulated without assistance and was a wanderer. The incident report reflected she had a wander guard in place. Review of the Provider Investigation Report provided by the ADM on 06/29/21 included a written statement from agency CNA YY that indicated around 10:15 PM, she was fixing to leave to go to Walmart and Resident #25 asked to go with her. CNA YY said no, but she would bring her something back. The CNA left (through which door unknown) and went to Walmart for about 20 minutes. She said in her statement that she propped the door open a crack because she was only going to be gone for a brief amount of time. When she returned to facility was when she saw the police returning Resident #25 to the front of the facility. Attempts were made to contact CNA YY on 06/29/21, 06/30/21, 07/01/2; messages were left on her voicemail but she did not respond. An interview with the ADM on 06/30/21 at 10:00 AM revealed she was asked if she was aware in the witness statement for CNA YY related to the second elopement of Resident #25, that she wrote she left the door open while she went to Walmart. The ADM said she was aware, and it initially concerned her but was it was not a factor in the resident's elopement. She said Resident #25 eloped through a different door, the front door. Observation of Resident #25 on 06/28/21 at 10:33 AM revealed she was in the secured unit in her bed. She was unable to be interviewed about the two elopements due to her cognitive status. An interview with the Activity Director (AD U) on 06/29/21 at 9:35 AM revealed Resident #25 had been moved recently to the secured unit. She said Resident #25 had tried to exit seek prior to the move and would want to find her car and want to look in the facility parking lot for it. She said she thought Resident #25 tried to go towards [local grocery store] on one of the times she eloped because it might have just looked familiar to her. An interview with the ADM on 06/29/21 at 5:18 PM revealed a factor with Resident #25's elopement was the poor weather; it was raining and storming. She said when the front door wander guard alarm went off during those times, she had talked with the team about not being dismissive about it. She said the night crew told her she did not understand that when the wander guard alarm went off on the front door, it could be a pain to come up to the front of the building to disarm it constantly. The ADM said the two elopements for Resident #25 blended together and she did not have any notes on the first one. She said, I was livid she got out again. She said for one of the elopements, Resident #25 was trying to follow a CNA out of the building who was going to Walmart. The ADM said a passerby found the resident and brought her back to the front of the facility where the CNA saw her upon her return from the store. The ADM said she could never get it straight if the resident was found in the Walmart parking lot or in the street immediately in front of the facility. She said Resident #1, must of high tailed it down the hallway to the front door. She said it was a very stormy night and when she talked to staff on the overnight shift told her the front exit door wander guard alarm kept going off. She said there was no way to disengage the wander guard alarm (turn it off completely). The ADM said when the front door wander guard alarm was going off that night, the staff may have assumed it was the weather causing it because it was thundering and storming. An interview with the RP/family member of Resident #25 on 7/03/21 at 7:52 AM revealed the facility only told him she had eloped twice, and the police had found her the first time. He said that was all the facility told him about it. He said he complained to them because she had a wander guard monitor on, and he wanted to know why the alarms did not go off. He said Resident #25's room was by the nurses' station where there was usually a lot of activity, So why didn't they see her leave? He said, I've seen alarms go off with different residents with bracelets and staff don't come. I have seen the door propped at night, the latest was 8 pm. The RP said he did not believe Resident #25 could have cut her wander guard bracelet off because she was not that agile or strong and was in a wheelchair and could only use her feet to scoot herself around. He said the facility never told him where she was found with the second elopement. They only told him she did it again and they were moving her to the memory care unit. 2. Review of Resident #68's quarterly MDS assessment dated [DATE] revealed he was [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] from an acute hospital stay. He had active diagnoses of non-Alzheimer's dementia, [CONDITION(S)], congestive heart failure, hypertension, gout, diabetes and cancer. His BIMS score was 04, which indicated severe cognitive impairment. He had minimal difficulty hearing, was usually understood and had impaired vision. He had no symptoms of [CONDITION(S)], [CONDITION(S)] or wandering behaviors. He used a wheelchair for mobility, had range of motion impairment in his lower extremities on both sides and required limited physical assistance of one staff to ambulate in his wheelchair. Review of Resident #68's care plan was initiated 03/04/19 and revised on 03/24/21 to include: The resident is an elopement risk/wanderer related to history of attempts to leave the facility unattended; placed in memory care for elopement risk. Interventions were to assess for fall risk, reside in secured unit for safety, distract resident from wandering by offering pleasant diversional activities and identify pattern of wandering. Review of Resident #68's elopement incident report dated 02/25/21 at 3:12 pm and written by LVN P reflected, When this nurse arrived to work resident was rolling around building in w/c. Last this nurse saw resident was in room in w/c. This nurse asked if resident was going to go to bed and resident said yes. About 0300 a man from the local pizza restaurant called the facility and informed us that a resident was outside by the [pizza restaurant] and he had called the local police and asked if we could come get resident. This nurse and CNA went to get resident and this nurse and the other nurse on duty talked the (sic) [city] police. No injuries were observed at the time of the incident. The incident report reflected no predisposing environmental, physiological or situational factors. Review of the Provider Investigation Report submitted after the elopement, yielded no interviews with the staff who worked the night Resident #68 eloped, no interview with Resident #68, no interview of who found him, what door he left from or why he left. The summary provided by the abuse and neglect coordinator stated, At approximately 3:30 am, DON called ADM to notify of an elopement. [Resident #68] was found by a delivery person across [street in front of facility] near the [name] pizza restaurant. He appeared to be unharmed and unalarmed. He had a notebook with facility name written in it. He contacted the police who in turn contacted the facility. Resident aide was sent to collect [Resident #68] and bring him safely back. Upon return, resident was assessed for injury and was without injury. Although [Resident #68] will sometimes roam the facility, he had not been observed to have any exit seeking behavior in a long while. He did not have a wander guard ordered. [Resident #68] was placed on 1:1 and then admitted to the Memory Care Unit. Observation of Resident #68 on 06/28/21 at 9:33 AM revealed he was in the secured unit of the facility. He was observed to participate in an exercise ball throwing activity and then a singing activity where he was observed to sing some gospels. He was in a wheelchair and not interviewable to the incident related to the elopement. An interview with Resident #68's RP/family member on 06/29/21 at 10:10 AM revealed he did not know why the resident left the building in the middle of the night, as he was usually asleep. The RP also questioned why the door alarm did not trigger at two or three in the morning when he wandered out of the building and how no staff saw him leave. He said Resident #68 would have had to use his wheelchair or walker in order to leave. He said Resident #68 did not go out the front exit door, he went out the side door which was emergency exit door with an alarm. The RP said when Resident #68 eloped, he was found by the police. He said it was about a week before the city experienced a snowstorm and power outages in February 2021. He said a couple of weeks after the incident, he went up to visit him around 7 in the evening and he figured the facility's front door was supposed to be closed and he would have to ring the bell to get in. However, the door was wide open. He said he kept trying to ring the doorbell to let them know he was there and about 20 minutes later, someone from the housekeeping department happened to walk by. He said he reported it to the business office manager and, she was like my god, and they wonder why the state is up in here all the time. The RP said after the incident, he had not heard from the facility to follow up on how they think he may have eloped. He said he agreed to place Resident #68 in the secured unit for his safety. An interview with the ADM on 06/29/21 at 4:44 PM revealed the staff told her when Resident #68 came back from his [CONDITION(S)] days, he was confused and exit-seeking, so she did not know if [CONDITION(S)] was causing him a decline. She said she thought she interviewed staff, but she had trouble ascertaining who brought him back because [pizza restaurant] would have been closed that time of night and was not open. The ADM said she talked to Resident #68 about the elopement but did not document it and could not recall what he said. She said she thought she asked him what happened, and he did not say anything so she left it at that. She said, I am getting my elopements confused. I am trying to remember who was working. The ADM said the front door of the facility would not have alarmed, even in the middle of the night if he did not have a wander guard on. She said, We don't know for sure if he went out the front door .at night, the front door is a dead zone. She said his room was in the back of the building on the 300 hall and it was not uncommon for him to roll around in his wheelchair at all hours. The ADM said Resident #68 had never attempted to elope before. She confirmed she did not have any documented interviews with staff on how he may have eloped on their shift. The ADM was asked what processes were put to place to prevent future elopements. She replied, We did some elopement in-servicing and I will confess we did schedule an elopement drill but didn't do it. She said the reason she did not complete an elopement drill was because she had just hired an interim DON and then HHSC regulatory was in the building for a visit, It just didn't get done. She said she hired a new DON and considerable training was completed on elopements and wandering, and emergency codes were updated and colors, but we didn't do a proper drill. The ADM said a drill would have been important because it was one more layer of intervention and it kept the issue fresh on the staffs' minds. An interview with LVN P on 07/02/21 at 2:49 PM revealed she was working at the facility during the elopement of Resident #68 and she was the charge nurse the night he left the facility. She said it was on the overnight shift and she remembered a nurse had called in so she had few extra rooms and he was one of them. LVN P said he was sitting by his room and she tried to put him to bed between 11:00 PM to midnight, but he did not want to. She continued to do her duties and she thought Resident #68 put himself to bed. She told the aides to make sure he went to bed because at that point, he was one we didn't have to worry too much about. She then said she got a call from the local police department around one or two in the morning that informed her Resident #68 was outside and someone had seen him walking. She said, I was like, how is he walking? LVN P said Resident #68 used a wheelchair for mobility so she did not know how he could have been walking. She said she never heard an alarm sound on any of the emergency exit doors. She said one of the doors must have been propped open and she was just guessing that because a lot of staff had been propping doors open at that point in the facility. She said she did not know why staff were propping doors open and she never actually saw a door propped open that night, she was guessing based on what she had been seeing. LVN P said Resident #68 did not have a wander guard on at the time of elopement. She said when he was brought back to the facility, she did an assessment and he had no injuries and was asking what all the fuss was about, that he was just going to [CONDITION(S)]. She said he was observed to have his notebook on him that he took to and from [CONDITION(S)], but he did not appear to have a change in condition cognitively that was different from his baseline. 3. Review of Resident #1's discharge MDS assessment dated [DATE] reflected she was an [AGE] year old female admitted to the facility on [DATE] from another nursing home. Her active diagnoses included fracture of the neck of the right femur (healing), heart disease, hypertension, type 2 diabetes, [CONDITION(S)], cardiac pacemaker and abnormalities of gait and mobility. Her BIMS score was 00, indicating severe cognitive impairment. She had no symptoms of [CONDITION(S)], [CONDITION(S)] or wandering behavior. Resident #1 used a wheelchair for mobility and required supervision when ambulating once in her chair. Review of Resident #1's care plan initiated 04/25/21 revealed she was at risk for falls and seizures, had muscle weakness and impaired mobility. Her care plan was revised on 05/10/21 to add the following problem: The resident is an elopement risk/wanderer related to attempts to leave facility unattended. Interventions included distract resident from wandering by offering diversional activities, identify pattern of wandering and Wander alert-check for placement q shift and function q monthly. Review of Resident #1's elopement incident report dated 05/07/21 at 6:15 PM revealed she was observed by a dietary staff to be outside in her wheelchair leaving the parking lot. Dietary staff then notified nursing staff and a CNA went to assist resident back inside the facility without incident. Resident #1 stated that she just wanted to go out. Resident #1 sustained no injuries. Her mental status was alert and oriented to person only. Predisposing physiological and situation factors indicated she was confused, had impaired memory, gait imbalance and a recent room change. Review of the Provider Investigation Report completed after the incident, revealed the it remained unknown if Resident #1 went out a door that the alarm was bypassed or if the system had not been re-armed after the last alarm went off. Preventatively, the team was in-serviced on responding to alarms and then resetting alarms immediately. The ADM documented it was suspected that Resident #1 may have been disoriented on the hall as she had moved several times in a short period of time. An interview with the ADM on 06/29/21 at 5:05 PM revealed she did an in-service with staff after the elopement incident, but did not obtain any statements or interviews from staff who saw her outside or from Resident #1. She said it was Resident #1's elopement when she realized staff did not know how to reset the front door after the wander guard was triggered. The ADM was asked how she knew Resident #1 took off her wander guard as was stated in her Provider Investigation Report. She said when Resident #1 was found and brought back inside, her wander guard was off. She said she could not actually verify when it came off, and she assumed the resident had cut it off, but no one actually saw her do that and she did not ask Resident #1 directly. The ADM said she did not know how Resident #1 got out of the building. She thought maybe she left through the exit door across from her office next to the entrance of the therapy gym but was not sure. She said she talked to ADON B who said there was a lot of activity in the facility the day Resident #1 eloped and there were vendors in the building repairing things going in and out of the exit doors. The ADM said Resident #1 was probably agitated due to the level of activity in the facility. When Resident #1 eloped, the ADM said she believed the wander guard or door alarm had not been activated, or the door was engaged and alarmed, and staff reset it without realizing a resident had eloped. She said ADON B and her discussed the door alarm system and wondered if the two wander guard doors had to be reset after they were silenced, or did they come back on automatically. The ADM said she still did not know. The ADM said, I can see that I did not do a thorough job. She said at that time, she was wearing several hats, including human resources, DON and social worker. An interview with Resident #1's responsible party/family member on 07/01/21 at 7:49 PM revealed her mother was unhappy with the facility and she told her she was leaving that place prior to the elopement. The RP said she did not relay Resident #1's comments to the facility because half of her thought the resident was just mad that she had been placed there, but then the other half of her thought Resident #1 might have been really unhappy. She said Resident #1 had admitted a month prior. The RP said when Resident #1 eloped, it had rained really bad. The RP said when Resident #1 told her she was going to leave, she said over and over again that the staff just did not care. She said she would push the call light and they did not come, even when she needed to use the bathroom. She said, I know they cannot watch each patient 24/7, but she went out the front door and took off, she went down the hill to the road. She said the front exit door was unlocked from the inside so anyone can push it and walk/roll out. She said after Resident #1's first elopement, the facility placed a wander guard on her, and she tried again to leave with another resident, but was not successful. The RP said the elopement happened on an evening shift on the weekend. She said the front exit door had no chime upon exit so staff would not have known Resident #1 left the facility because she had no wander guard on at that time. To come back inside the facility, the RP said the door locked the person out. The RP said she felt there was negligence because Resident #1 was able to exit the facility and make it to the road in front. 4. Review of Resident #33's quarterly MDS assessment dated [DATE] revealed she was an [AGE] year old female admitted to the facility on [DATE]. Her active diagnoses included non-Alzheimer's dementia, chronic obstructive pulmonary disease, persistent mood disorder, hypertension and [CONDITION(S)]. Resident #33's BIMS score was 08, which indicated moderately impaired cognition. She had signs and symptoms of [CONDITION(S)] during the assessment period, which included inattention that was present but fluctuated. She had no indicators of [CONDITION(S)] or behavioral symptoms and was assessed as not having exhibited wandering behavior. Resident #33 used a wheelchair for mobility and range of motion impairments on her lower extremities on both sides. She required extensive assistance of two staff to ambulate in her wheelchair. Review of Resident #33's care plan initiated 03/22/19 reflected a problem initiated on 06/01/21: The resident is an elopement risk/wanderer. History of attempts to leave facility unattended. Impaired safety awareness. Interventions: Direct resident from wandering by offering pleasant diversions; identify pattern of wandering; Wander alert-check placement q shift and function d day shift. Review of Resident #33's elopement incident report dated 05/28/21 at 4:30 pm revealed she was found by facility staff in her wheelchair outside the back door. She stated that she was looking for the airplane. No injuries were observed at the time of the incident. Predisposing physiological factors indicated Resident #33 was confused and incontinent. Review of the Provider Investigation Report completed after the incident, revealed only a summary of the investigation. There was no evidence of follow up training, no evidence of witness statements from staff or resident and no monitoring plan going forward of the alarm system. The ADM documented in the report that a CNA saw Resident #33 outside the back exit of the building between the vending machines and the laundry room (approximately 15-20 feet from exit). He told her the door had been propped open and facility staff were taking laundry into the building. After that incident, a wander guard was placed on Resident #33. The Provider Investigation Report reflected that education was done with facility staff on the importance of keeping aware of the back door, particularity when it was open for any length of time. An interview with Resident #33 on 07/02/21 at 1:35 PM revealed she was in her room in her wheelchair finishing lunch. She appeared a disheveled looking in her clothes and her conversation style expressed annoyance in answering questions. She was asked if she had ever attempted to leave the building before. She said no. She was asked about the elopement incident and she replied, That is a damn lie. She then said she wanted to leave and if she had the means and a way to get home, she would roll right out the door and leave. She was asked if she had a wander guard bracelet on her person or wheelchair. She said, If I did, y'all would never know. A wander guard was observed on her left ankle under her socks. An interview with the ADM on 07/02/21 at 12:13 PM revealed Resident #33 eloped when laundry staff and agency CNAs were bringing carts in and out of the facility. The ADM said she had talked to Resident #33 shortly before she eloped and she had told the ADM she was looking for the airplane, not terribly unusual. She said no alarm would have sounded on the back door because it was a wander guard protected door only and Resident #33 was not wearing a wander guard at the time. Further interview with the ADM on 07/02/21 at 2:08 PM revealed she did an in-service about door propping but she could never identify the staff who were doing it and she re-iterated the importance of not encouraging residents to leave and if staff needed to come in the building to bring laundry in, have another staff member present to be on the lookout. The ADM said she did not have anything to show she talked to the specific people involved who had left the door open. 5. Review of Resident #99's quarterly MDS assessment dated [DATE] revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] from an acute hospital stay. His active diagnoses included [CONDITION(S)] disease, [CONDITION(S)], chronic obstructive pulmonary disease, coronary artery disease, [CONDITION(S)] and hypertension. His BIMS score was 12, which indicated moderately impaired cognition. He had no symptoms of [CONDITION(S)], [CONDITION(S)] or wandering behaviors. He used a wheelchair for mobility and had range of motion impairment on both sides of his upper and lower half of body. He required extensive physical assistance of one staff for ambulation in his wheelchair. Review of Resident #99's care plan reflected it was initiated on 06/23/20 and updated on 03/17/21 and reflected: Resident exhibits history of wandering related to impaired safety awareness. Interventions included distract resident from wandering by offering pleasant diversions and wander guard in place-check for placement q shift and for function q monthly. Review of Resident #99's quarterly Wandering/Elopement Risk Evaluation completed 05/16/20 indicated he was at moderate risk for wandering. Review of Resident #99's elopement incident report dated 06/22/20 at 4:30 pm revealed he was found outside in his wheelchair in the far back parking lot. He stated that he was looking for, [NAME], the lady with all the kids that's going to marry me. No injuries were observed at the time of the incident. Predisposing physiological factors indicated Resident #33 was confused and it was his first elopement from the facility. Review of Provider Investigation Report for Resident #99 submitted to HHSC revealed the incident occurred at 4:30 PM on 06/22/20 and when he was brought back inside from being found at the back of the parking lot, he had a small scab to his left lower leg. The report stated he was not negatively impacted but appeared to be suffering from delusions. A wander guard was placed on his leg. The abuse and neglect coordinator documented, Facility Action taken Post-Investigation-facility recognizes the negligence in allowing the resident to exit the building without being observed. With no history of wandering, there had previously not been a concern to monitor for this behavior. Staff education and in-servicing on Elopement and Wandering behaviors as well as abuse and neglect reporting has and will continue to be administered. An interview and observation with Resident #99 on 06/29/21 at 10:38 AM revealed he remembered when he left the facility last summer. He said it happened about two weeks after he had arrived at the facility. He said he had just seen his doctor and he thought the doctor had said that he could leave, so he packed up and left the building to go back home. He said he was brought back in and staff placed a wander guard on him. He pulled back his blanket and his wander guard was observed to be on the ankle of his left leg. Resident #99 stated he missed being at home and his ultimate goal was to move back home. 6. The ADM was asked on 06/28/21, 06/29/21, 06/30/21 and 07/01/21 to provide evidence of facility staff training provided after each elopement, as was part of the documented facility action that would be taken after the elopements. On 07/02/21, she was unable to provide any evidence that staff had been trained on elopement protocols/wander guards, propping doors open and alarm system guidelines. An observation of the facility's front exit door on 06/28/21 at 10:51 AM revealed the it had a keypad next to it. When the door bar was pressed, the door opened without any auditory alarm. When outside, the door was locked. The doorbell on the exterior of the building did not work. An observation occurred on 06/29/21 at 11:12 AM with the consent of Resident #75 to use her wander guard ankle bracelet to check its function for the two wander guard alarms at the front and back doors. At the back-exit door, her foot with the wander guard bracelet went all the way to the door and touched it, and there was no alarm. The door was then pushed open and there was no auditory alarm. At that time, CNA Q was present and did not know what was going on with the wander guard alarm or how to make it armed. LVN O came to the door and tried to put in a code turn the wander guard system on. Resident #75 was pushed to the door again with no alarm sounding. The door was able to be opened freely. The MD approached and said Resident #75's wander guard bracelet should be triggering the alarm. LVN O put in the alarm code again and the wander guard alarm worked. LVN O said the alarm code had recently been changed and she had forgotten to put an * after the code. The MD and CNA Q both stated at that time they did not know how to reset/disarm the wander guard back exit door. Then Resident #75's wander guard bracelet was used at the front door. When she got within about four feet, the alarm triggered loudly with no issues; the front desk receptionist came and reset the alarm at the keypad at the door. An observation on 06/29/21 at 4:40 PM revealed the administrator's office door was open but she was not present nor were any other staff or residents in the hallway. Across from her office was one of the six exterior exit doors; it did not have a wander guard detector on it. The door was observed to be propped open with a plank of wood several inches. A sidewalk led from the door outside around to the parking lot and subsequently the front of the building. An vendor was observed to be outside working on air conditioning equipment near the exit door. An interview with [TRUNCATED]

Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with standards of practice and based on the comprehensive assessment for 6 of 6 residents reviewed for quality of care (Residents #3, #35, #36, #39 #45, and #71#) AD F, CNA C, CNA D and CNA E gave whole popcorn to Residents #3, #35, #36, #39, #65, and #71 who were on a physician's ordered dysphagia advanced diet due to aspiration precautions. Resident #35 did not receive assistance during oral intake of popcorn per her physician's order. Staff present while the residents ate popcorn failed to intervene when 3 of 6 residents (Resident #35, 71, and #45) displayed signs of aspiration (coughing) while consuming popcorn. This failure placed residents who required mechanically altered diets (advanced dysphagia diets) at risk for aspiration (food or liquid entering the airway), aspiration pneumonia, choking, hospitalization , or death. On 06/29/21 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/01/21, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 06/29/21 at 8:11 PM. Findings Included: Record review of Resident #35's Face Sheet dated 06/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#35's Physician order summary report dated 06/30/21 revealed an order start date 01/20/21 for Regular diet Regular texture, Honey consistency, for aspiration precautions. Total Feeding Assistance, with no end date. Record review of Resident #35's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 8 signifying a moderate cognitive impairment The MDS also indicated Resident #35 needed supervision and set-up assistance for eating. Review of Resident #35's Care Plan, undated, revealed in part: Problem . Altered Nutritional Status . Assist with meals as indicated . Offer diet per orders . Problem .potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #71's Face Sheet dated 06/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#71's Physician order summary report dated 06/30/21 revealed an order start date 07/30/20 for Regular diet Dysphagia Advanced texture, Regular consistency, with no end date. Record review of Resident #71 Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 2 indicating severely impaired cognition. The MDS also indicated Resident #71 needed extensive assistance with one staff for eating. Review of Resident #71's Care Plan, undated, revealed in part: Problem . I have an ADL Self-Care Performance Deficit muscle weakness . Eating: I require supervision/set-up to maintain independence/safety . Problem . I have potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #71's Speech Therapy Plan of Care dated 11/30/20 reflected the following: Patient is an [AGE] year old female long-term resident at this facility who was referred/screened per clinician to ST services . Skilled therapy is necessary to improve oropharyngeal dysphagia . Functional Deficits .Swallowing, oral phase .Swallowing, pharyngeal phase . facility staff will demonstrate comprehension and functional utilization of diet modifications, aspiration precautions, and feeding assistance recommendations as indicated . Dysphagia/ Aspiration Precautions include: mechanical soft diet, staff to prompt for adequate intake. Feeding assistance as indicated . Record review of Resident #45's Face Sheet dated 06/30/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#45's Physician order summary report dated 06/30/21 revealed an order start date 10/19/20 for Regular diet Dysphagia Advanced texture, Regular consistency, with no end date. Record review of Resident #45's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 4 indicating severely impaired cognition. The MDS also indicated Resident #45 needed supervision and set-up assistance for eating. Review of Resident #45's Care Plan, undated, revealed in part: Problem . I have potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #45's Speech Therapy Plan of Care dated 01/19/21 reflected the following: Patient is an [AGE] year old male long-term resident at this facility who was referred/screened per clinician to ST services . Skilled therapy is necessary to improve oropharyngeal dysphagia . Functional Deficits .Swallowing, oral phase .Swallowing, pharyngeal phase . seen at bedside .missing dentition on top and is edentulous on bottom . continue Dysphagia Advanced Diet . Record review of Resident #36's Face Sheet dated 06/30/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#36's Physician order summary report dated 06/30/21 revealed an order start date 02/04/21 for Regular diet Dysphagia Advanced texture, Regular consistency, for Aspiration Precautions. Monitor for adequate intake, with no end date. Record review of Resident #36 Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 0 indicating severely impaired cognition. The MDS also indicated Resident #36 needed supervision and set up assistance for eating. Review of Resident #36's Care Plan, undated, revealed in part: Problem . I have an ADL Self-Care Performance Deficit [related to diagnosis] dementia . I require supervision with 1 staff participation to eat . Problem . [Resident #36] has a potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #36's Speech Therapy Plan of Care dated 01/19/21 reflected the following: Patient is an [AGE] year old female long-term resident at this facility who was referred/screened per clinician to ST services due to significant weight loss . Skilled therapy is necessary to improve oropharyngeal dysphagia .Functional Deficits .Swallowing, oral phase .Swallowing, pharyngeal phase .Cognition, Mental Status . confused . following recommendations: mech[anically] soft diet . Record review of Resident #39's Face Sheet dated 06/30/21 revealed he was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#39 's Physician order summary report dated 06/30/21 revealed an order start date 06/10/21 for Consistent Carbohydrate (CCD) diet Dysphagia Advanced texture, Regular consistency, with no end date. Record review of Resident #39's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 3 indicating severely impaired cognition. The MDS also indicated Resident #39 needed supervision and set-up assistance for eating. Review of Resident #39's Care Plan, undated, revealed in part: Problem . potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #39's Speech Therapy Plan of Care dated 08/07/20 reflected the following: .referred to ST services for assessment of swallowing and cognitive-communication strategies . Precautions: fall risk, dysphagia, sundowning, mechanical soft . seen at bedside . Reduced strength and coordination of lingual muscle . Recommend downgrade to mechanical soft . Record review of Resident #3's Face Sheet dated 06/30/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#3's Physician order summary report dated 06/30/21 revealed an order start date 01/06/21 for Regular diet Dysphagia Advanced texture, Regular consistency, Frozen nutritional treat with meals for Aspiration Precautions. Check for pocketing, with no end date. Record review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not documented. The MDS also indicated Resident #3 needed supervision and set-up assistance for eating. Review of Resident #3's Care Plan, undated, revealed in part: Problem . ADL self-care performance . Eating: The resident can: feed self [with] supervision The resident requires limited assistance by 1 staff to eat . Problem .potential nutritional problem .Monitor/document/report PRN any [signs/symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts to swallow, Refusing to eat, Appears concerned during meals . Provide and serve diet as ordered. Monitor intake and record [every] meal . Record review of Resident #3's Speech Therapy Plan of Care dated 01/06/21 reflected the following: Patient is an [AGE] year old male long-term resident at this facility who was referred/screened per clinician to ST services . Functional Deficits .Swallowing, oral phase .Swallowing, pharyngeal phase . demonstrates ability to safely swallow Mechanical soft/ Dysphagia Advanced, small pieces diet using compensatory strategies from trained staff . Facility staff and familial caretakers will demonstrate comprehension and functional utilization of aspiration precautions, diet modifications, and prompting/assistance recommendations in order to facilitate safe and efficient nutrition .] Observation at the memory care unit on 06/29/21 at 1:45 PM revealed Residents #45, #36, #39, and #3 were provided popcorn in disposable cups. Resident #71 received a plateful of popcorn while sitting at a dining room table. AD F, CNA C, CNA D, and CNA E handed the popcorn to the residents. While eating the popcorn, Resident #71, Resident # 45, and Resident #35 began to cough. Resident #35's face became red and produced a wet sounding cough. Resident #71 and #45 produced a dry cough. The residents alternated coughing for approximately 2 minutes. Staff present during the coughing included AD F, CNA C, CNA D, CNA E, and LVN A. None of the staff intervened while the residents were coughing , and the residents continued to eat popcorn. In an interview on 06/29/21 at 2:45 PM, SLP G stated a dysphagia advanced diet was a mechanical soft texture. She said the meats would be chopped, sides would include soft foods, and foods would be cooked a little longer to be soft. When asked the reason a resident would be ordered a dysphagia advanced diet, SLP stated it would be ordered for someone if they had no teeth or bad dentition and were not able to chew up the regular or if they had oral or pharyngeal dysphagia to reduce the risk of food going into their lungs and aspirate. When asked if a resident on an advanced dysphagia diet could eat popcorn, SLP stated no because the resident could aspirate and choke. SLP said signs of aspiration included coughing, turning red, nose starts to run. If you had a pulse ox, O2 sats may drop. When asked what she would do if she were notified a resident on a dysphagia advanced diet ate popcorn, SLP said, I would assess [the resident] and educate the staff on appropriate diets. In an interview on 06/29/21 at 3:25 PM CNA C stated that a resident ordered a mechanical soft diet has meats that are chopped. She stated a resident may be placed on a mechanical soft diet if they had difficulty swallowing or issues with their teeth. CNA C said the popcorn activity occurs once or twice a week. She said popcorn was a choking hazard for residents and CNAs watch them while they're eating it. When asked if she had received training about that popcorn and choking hazards, she said, I've heard that at another facility. CNA C stated she was never told residents ordered a mechanical soft diet cannot eat popcorn. CNA C further stated, It's normal for [residents] to have popcorn, that's why we keep [residents] on our observation. CNA C denied hearing Resident #71 and Resident #45 coughing. In an interview on 06/29/21 at 3:35 PM CNA D stated that a resident ordered a mechanical soft diet has meats that are ground or chopped up, that way they can chew it and get it down. When asked the reason a resident would be ordered a mechanical soft diet, CNA D stated it would be for a resident who had issues with swallowing or issues with their teeth or chewing. When asked how often residents received popcorn with activities, CNA D said one or two times a week. She further stated that residents ordered a pureed diet are given pudding or applesauce, but residents ordered a mechanical soft diet can eat popcorn. CNA D further stated, We watch [the residents] because anybody can choke off popcorn, even if they eat regular food. I've never been told that anyone on mechanical soft diet shouldn't have popcorn. In an interview on 06/29/21 at 3:46 PM AD F stated residents receive popcorn as an activity once a week or once every two weeks. When asked who receives food alternatives to popcorn, AD F said, most of them can have it, the only ones that can't have [popcorn] are the ones that are on pureed. When asked if residents ordered a mechanical soft diet can have popcorn, AD F stated, I would think so, as long as they're not eating the seeds. AD F stated no one had told her residents ordered a mechanical soft diet cannot have popcorn. AD F stated she did not hear any of the residents coughing while eating popcorn. In an interview on 06/29/21 at 3:52 PM, LVN A said residents receive popcorn once a week, and there was pudding or applesauce available for residents ordered a pureed diet. LVN A stated she did not hear any of the residents' cough while eating popcorn but that some residents cough all the time. When asked if residents ordered a mechanical soft diet should eat popcorn, LVN A stated, They probably shouldn't have it, but that's why I am there watching them. LVN stated she had not been told residents ordered a mechanical soft cannot have popcorn. In an interview on 06/29/21 at 4:03 PM, the DON said a dysphagia advanced diet was a mechanical soft diet. She further stated a resident would be ordered a dysphagia advanced diet if they had dysphagia, and if a MBSS documented that's what [the resident] can tolerate safely. When asked what would happen if a resident were to receive food that was not appropriate for their ordered diet texture, the DON said the resident could aspirate or choke, up to death. When asked if residents ordered a mechanical soft diet could eat popcorn, the DON said, I don't want them to have popcorn, I don't feel comfortable with them having it. The DON further stated that a resident ordered a mechanical soft diet should not have popcorn because they could choke or aspirate. When asked what she would expect a nurse to do if a resident ordered a mechanical soft diet was coughing while eating, the DON stated the nurse should get up and see why [the resident was] coughing. Review of the facility's June 2021 activity calendar reflect Movie and Popcorn Social, were scheduled for the following dates: 06/02/21, 06/03/21, 06/10/21, 06/17/21, 06/22/21, and 06/24/21. Review of the facility policy titled Diet Nutrition Care Manual, dated 2019, reflected in part: Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet This diet is used for individuals with mild oral and/or pharyngeal dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. Food should be prepared according to individual tolerance to the food. Any foods that are very hard, sticky, chewy, or crunchy should be avoided . Foods to Avoid . any dry, tough or crusty bread . crackers . toast . dry crunchy cereals . popcorn .chips . Review of Optimizing Texture Modified Foods for Oro-pharyngeal Dysphagia: A Difficult but Possible Target?, dated 2018 and accessed on 07/08/21 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 51/, reflected the following: Dysphagia is a swallowing disorder characterized by the difficulty in transferring solid foods and/or liquids from the oral cavity to the stomach, impairing autonomous, and safe oral feeding. The main problems deriving from dysphagia are tracheo-[MEDICATION(S)] aspiration, aspiration pneumonia, malnutrition and dehydration . Oropharyngeal dysphagia (OD) is a dysfunction of the digestive system, consisting of a difficulty in swallowing which affects the proper transit of the bolus in the upper digestive tract. The main complications of dysphagia are tracheo-[MEDICATION(S)] aspiration (food transit in the airways with choking), aspiration pneumonia (pneumonia caused by food in the lungs), malnutrition and dehydration . Dysphagic patients fail to control food flow, which is fast and turbulent through the oropharynx, with the risk of misdirection through the respiratory tract . Review of Dysphagia in the elderly: management and nutritional considerations, dated 2012 and accessed on 07/08/21 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/, reflected the following: Dysphagia is a prevalent difficulty among aging adults. Though increasing age facilitates subtle physiologic changes in swallow function, age-related diseases are significant factors in the presence and severity of dysphagia. Among elderly diseases and health complications, stroke and dementia reflect high rates of dysphagia. In both conditions, dysphagia is associated with nutritional deficits and increased risk of pneumonia . Dysphagia is a common symptom in dementia. It has been estimated that up to 45% of patients institutionalized with dementia have some degree of swallowing difficulty.39 Different clinical presentations of dementia will result in different swallowing or feeding impairments.40-43 Most commonly, patients with dementia demonstrate a slowing of the swallowing process.14 Slowed swallow processes may increase time taken to finish a meal and subsequently increase the risk for poor nutritional status.14 Furthermore, patients with dementia often have difficulties self-feeding. These difficulties may relate to cognitive impairment, motor deficits such as weakness or [CONDITION(S)], loss of appetite, and/or food avoidance. As a result, patients with dementia may experience weight loss and increased dependency for feeding.14 Subsequently, increased feeding dependency may lead to other dysphagia-related health problems, including pneumonia.14 Weight loss can reflect decreased nutritional status which increases the patient's risk of opportunistic infections such as pneumonia.44-46 Pneumonia is a common cause of mortality in patients with dementia.47 Thus, dementia, dysphagia, and related feeding impairments can lead to nutritional deficits which in turn contribute to pneumonia and mortality. Among elderly patients in particular, the presence of dementia is associated with higher hospital admission rates and overall higher mortality . Diet modifications: modification of foods/liquids. Modifying the consistency of solid food and/or liquid is a mainstay of compensatory intervention for patients with dysphagia.37 The goal of diet modification is to improve the safety and/or ease of oral consumption and thus maintain safe and adequate oral intake of food/liquid. However, low acceptability and resulting poor adherence with modified foods/liquids can contribute to increased risk of inadequate nutrition in elderly patients with dysphagia . On 06/29/21 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/01/21, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 06/29/21 at 8:11 PM. The facility Administrator was notified on 06/29/21 at 8:08 PM that there was Immediate Jeopardy (IJ) identified due to the above failures. The Plan of Removal (POR) was accepted on 07/01/21 at 3:57 PM and it included the following: 1. On 06/29/2021 , upon discovery of concern: Station 1 Assistant Director of Nursing, [ADON B] and MDS coordinator, [MDS Coordinator], assessed the 6 residents identified (Resident #71, Resident #45, Resident #36, Resident #39, Resident #25, Resident #3] as receiving popcorn to determine ill toward effects from consumption and for signs and symptoms of aspiration; there were no negative findings for any of the identified 6 residents. Physician, and family were notified at 5:30pm by [ADON B], ADON and [MDS Coordinator], MDS. The Physician gave no new orders for any of the 6 residents. 2. On 06/29/2021: Station 2 Assistant Director of Nursing, [ADON R], added an order to Nurses' MAR for q shift monitoring of signs and symptoms of aspiration for a minimum period of 48 hours for the 6 identified residents, this was initiated at 10:11pm and will end at 7/1/2021 at 10:11pm. 3. Regional Registered Dietician, reviewed other residents within the facility for diet order types and identified other facility residents at risk to include residents with Advanced Dysphagia diets (mech soft). As of 6/29/2021, there are 46 out of 113 residents identified. 4. DON, and ADONs [ADON B] and [ADON R] in-serviced incoming and subsequent nursing team members, including Nurses and Nurse Aides/Med Aides: verifying meal orders prior to serving any meal/snack. At risk residents will be monitored while consuming any meals/snacks; monitoring will be in the form of observation while in dining areas and/or walking rounds if resident remains in room. Only diet appropriate snacks will be served to residents from facility staff. These departments will be responsible for consulting diet orders for consuming residents. 5. On 6/29/2021: DON, and ADONs [ADON B and ADON R] and MDS Coordinator provided a diet listing report that was posted at the nurse's station to identify those residents for communication to nurses, activities and nurse aides. Completed 6/29/2021. Staff informed of this addition during current and subsequent in services. 6. On Wednesday 6/30/2021, Licensed Speech Therapist [SLP BBB] is scheduled to further assess the identified 6 residents and will evaluate diet types for appropriateness. Anticipated completion date 6/30/2021. 7. On 6/29/2021, Registered Dietician cross referenced diets against Meal Tracker tray tickets with physician orders for accuracy and diet type and informed team of any variance. Completed 6/30/2021. 8. On 6/29/2021: Education regarding verifying diet orders and the addition of the diet listing report have been arranged via in-service to be given by DON, ADONs [ADON B and ADON R] and Certified Dietary Manager [DM] all staff and nursing agency beginning with those present in building on 6/29/21 at approximately 9pm. Any staff member or nursing agency not in attendance will be required to receive education prior to the start of their next scheduled shift. This will be followed up by a competency test. 9. On 6/30/2021; All staff and nursing agency will be educated with a separate in-service re: signs/symptoms of Aspiration. Education will be provided by DON, ADONs [ADON B and ADON R] and MDS Coordinator. Any team members not in attendance will be required to receive education prior to the start of their next scheduled shift. Lists from each department have been cross referenced with team members receiving education to verify completion of education. Anticipated completion date: 07/01/2021/ 10. On 6/29/2021: List of appropriate snack options for residents on Dysphagia Diets available to any team members administering snacks; list is located in same binder as resident's diet orders. Anticipated completion date: 06/30/2021. This will be followed up with a competency test. Monitoring of the plan of removal revealed: In an interview on 06/30/21 at 10:17 AM, the Regional Nurse stated that 6 residents (Residents #71, #45, #36, #65, #39, and #3) that were identified as having received the inappropriate diet texture were assessed by ADON B and the MDS Coordinator. She stated the assessment included lung sound assessment and vital sign assessment. She also stated that all the residents in the memory care unit would be assessed for signs and symptoms of aspiration. and assessed. She further stated the regional SLP arrived at 7:15 AM and was working on doing speech evals but started off on the memory care unit. An observation and interview on 07/01/21 at 12:49 PM revealed the MDS coordinator stated she received training on how to monitor residents, verification of knowing signs and symptoms of aspiration. Ensuring the safety of our residents during mealtime. When asked if there were any place nurses could review the information provided in the in-services, the MDS Coordinator stated there were posters in the nursing stations and it was also located in the diet book at the nurses' station. An observation of the nursing station verified the posters and diet book were present with specific diet information. The MDS Coordination stated that residents ordered a dysphagia advanced diet were not to receive popcorn. When asked the signs or symptoms of aspiration were coughing, nasal drip, runny eyes, grabbing throat, and choking. When asked what intervention would be implemented if the signs of aspiration or choking were noted while a resident was eating, MDS Coordinator said, First, remove the food, sit them up, assess and ensure there is no blockage. Check the color of their skin and lips. Watch their respirations. Listen to lung sounds for wheezing, check for fever, and check O2. If there are no negative findings, I would call the doctor to notify them of the coughing episode and of my assessment findings. Then the nurses would input a nurse's order to assess the resident for 48 hours including auscultation of lung sounds and vital signs. If I assess the resident and they are showing signs of choking, not breathing, turning blue, I would immediately call 911 and then call the doctor. In an interview on 07/01/21 at 1:01 PM, LVN L stated she had received training on the kinds of food that they can and can't have. We have a book with the different diets at every nurses' station. When asked, LVN L said residents ordered a dysphagia advanced diet were not to receive popcorn. LVN L stated that nurses make sure the meal ticket is the correct diet and correct texture. LVN L also said nurses would confirm resident snacks are the correct diet texture. When asked what would happen if a resident received food not appropriate for their ordered diet textures, she said residents could aspirate or choke. LVN L said the signs and symptoms of aspiration included: change in voice, drooling, coughing, fatigue, and secretions. LVN L said interventions for aspiration or choking included: making sure there is nothing in the resident's mouth, call the doctor and make them aware, check residents' respirations, listen to lung sounds, and assess vital signs. She stated when she would also continue to monitor and pass it on to the oncoming nurse in report. In an interview on 07/01/21 at 1:12 PM, CNA ZZ said she was an agency staff. CNA ZZ said she received an in-service and a test on altered diet and what foods items they can eat. She stated residents on a dysphagia advanced diet cannot eat popcorn. When asked where she would find what diet a resident was ordered, CNA ZZ stated she would look on the meal tickets or go to the charge nurse to ask about the diet. CNA ZZ said the signs of aspiration were coughing, choking, drooling, and holding their neck and if observed she would remove the object from their mouth and do the [MEDICATION(S)] if they were choking. She stated other interventions included put them in an upright position and report it to the nurse. Do not let [the resident] continue eating until the nurse approved. In an interview on 07/01/21 at 1:18 PM, CNA QQ said she received and in-service about diets. When asked the content of the training, CNA QQ said people on pureed or mechanical food, what they can and can't eat like grapes, peanuts. Mechanical people cannot have popcorn and can't eat peanuts or M&Ms. If I don't know the diet, I can go to the nurse or in the dining room I will look at the book for diets. CNA QQ further stated the nurses check the meals and snacks to make sure they are the correct consistency. When asked what would happen if a resident received food that was not the correct texture, CNA QQ said, They could aspirate or choke. CNA QQ said signs of aspiration included: nose running, eyes running, and coughing. She stated if she noted these signs while a resident was eating, she would stop the person from eating and call the nurse. In an interview on 07/01/21 at 1:24 PM, MA AAA said she received an in-service about people that was having difficulty swallowing and what is acceptable for them to take according to their diet. Mechanical soft can't have popcorn because they could choke. Look at their diet before you give [residents] anything. MA AAA said signs of aspiration were runny nose, watery eyes, and coughing. She stated if those signs were observed in a resident she would Stop and check and see what's wrong with them, tell the nurse, and stop them from eating. In an interview on 07/01/21 at 1:28 PM, CNA D she received and i [TRUNCATED]

Based on observation, interview and record review, the Administrator and the DON failed to utilize the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (Residents #5 and #11) of 22 residents who were reviewed for weight management, including maintaining acceptable parameters of nutritional status and body weight. 1. The ADM failed to supervise the DON to ensure nursing staff were educated and competent in nutritional management. 2. The DON failed to: a) monitor and supervise the supervisory and licensed/unlicensed nursing staff to ensure they were monitoring residents' meal intake, nutritional status, and body weight for Residents #5 and #11. b) monitor and supervise the supervisory and licensed/unlicensed nursing staff to ensure they recognized and addressed changes in residents' meal intake, nutritional status, and body weight for Residents #5 and #11. c) monitor and supervise the supervisory and licensed nursing staff to ensure they were monitoring care plans and formulating individualized care plans to include goals/approaches specific to residents' meal intake, nutritional status, and nutritional/body weight changes for Residents #5 and #11. d) monitor and supervise the supervisory and licensed nursing staff to ensure residents' food likes and dislikes were explored for residents with poor nutritional intake and changes in nutritional status and body weight for Residents #5 and #11. e) monitor and supervise the supervisory and licensed/unlicensed nursing staff to ensure residents with poor nutritional intake and changes in nutritional status/body weight were monitored, encouraged to eat, and/or were assisted with meals to increase food intake for Residents #5 and #11. f) monitor and supervise the supervisory and licensed nursing staff to ensure the percentage of residents' meal intake was monitored and accurately documented to ensure changes in nutritional status and body weight were identified for Residents #5 and #11. g) monitor and supervise the supervisory and licensed/unlicensed nursing staff to ensure there was interdisciplinary communication regarding residents' meal intake and changes in nutritional status and body weight for Residents #5 and #11. h) educate, monitor, and supervise the facility's licensed/unlicensed nursing staff to ensure they were competent in 1) monitoring residents' need for encouragement and/or assistance with meals, 2) accurately documenting percentage of meal intake, 3) recognizing changes in nutritional status and body weight, and 4) developing and implementing interventions to address changes in nutritional status and body weight for Residents #5 and #11. 3. Resident #11 was readmitted on [DATE] following a [MEDICAL CONDITION] with surgical repair. His weight on readmission was 136.7 pounds. On 08/02/12, 15 days later and after surveyor's intervention, Resident #11 was weighed at 111.7 pounds, representing a 25 pound weight loss (18%). 4. Resident #5's intake was not accurately monitored, she was not provided encouragement for meal intake or offered substitutes as per her plan of care. Between July and August 2012, Resident #5 had a 6.6% weight loss. An Immediate Jeopardy (IJ) was identified on 08/02/12. While the IJ was removed on 08/03/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring its Plan of Removal. These failures contributed to the significant/severe weight loss of Residents #5 and #11 and could affect the 18 residents identified by the facility with body weight/nutritional concerns. Findings included: 1. Resident #11 was an [AGE] year-old male who was readmitted to the facility on [DATE] according to the resident's significant change MDS assessment dated [DATE]. His active [DIAGNOSES REDACTED]. Resident #11 had short term and long term memory deficits with severely impaired decision-making ability. His ability to make concrete requests was limited and he responded adequately only to simple, direct communication. Resident #11 frequently had episodes of difficulty concentrating. The assessment reflected the resident did not have a poor appetite. Review of Skilled Nurses Notes dated 07/18/12 revealed Resident #11 was hosptalized on [DATE] due to a fall and subsequent [MEDICAL CONDITION]. The resident returned to the facility on [DATE]. His admission weight was 136.7 pounds. Review of the resident physician's orders [REDACTED]." The most recent HCP dated 07/24/12 reflected Resident #11 required the assistance of one person for all other ADLs, including eating. The goals included to maintain the resident's current weight during the next 90 days. Approaches to the goals included: ? Assess for difficulty chewing/swallowing and refer to ST as indicated; ? Assist with meals as needed; ? Provide snacks between meals; ? Dietary consult for nutritional assessment; ? Monitor appetite and encourage intake at each meal; ? Offer substitue if < 50% eaten at a meal; ? Provide supplement as ordered; and ? Monitor weight q month and weekly as needed. No other concerns associated with nutrition were addressed in this HCP. On 07/31/12 at 9:35 a.m., Resident #11 was observed in a geri-chair being pushed to his room by staff. The resident was very lethargic and seemed weak and fatigued. The resident's arms were exposed and appeared every thin with little muscle mass. UM R revealed at that time that Resident #11 was fed by staff and he had a significant weight loss. UM R stated the resident had a surgical site on his leg due to a recent hospitalization for a [MEDICAL CONDITION]. She stated the surgery site was healing. UM R stated the resident was working with therapy but was unable to bear weight on his leg since his surgery. Resident #11's lab reports were reviewed for nutritional parameters and revealed the most current lab values were dated 03/13/12. The nutritional parameters at that time reflected: Blood Glucose - 68 (normal 70 - 110 mg/dL); Total Protein - 5.4 (normal 6.4 - 8.2 g/dL); and [MEDICATION NAME] - 3.0 (normal 3.4-5.0 g/dL). No pre-[MEDICATION NAME] or iron levels were reflected in the lab report. Resident #11 was observed on 07/31/12 at 12:15 p.m. in the ADR. He was seated at a horseshoe dining table facing the wall. A glass of thickened cranberry juice was on the table in front of him. Resident #11 nodded off to sleep. At 12:25 p.m. on 07/31/12, the resident's tray with a pureed diet with thickened liquids was placed in front of him. The resident was immediately awaken and propelled to the therapy room. The resident appeared dis-interested and fell back to sleep during the trip. At 12:30 p.m. in the therapy department, the resident was placed at a table where he attempted to feed himself but was too weak to hold the spoon. An individual, identified as a therapy student, attempted to feed the resident while attempting to stimulate his swallow reflex by rubbing his throat. Resident #11 remained extremely lethargic and could not stay awake. With each attempt to feed, the resident had to be awakened and cued to swallow each bite offered. The student managed to get the resident to eat in small spoonfuls, one spoon of spinch, two spoons of pudding and one spoon of fortified potatoes. The student left the resident at that time. At 12:38 p.m., COTA A attempted to feed Resident #11. The COTA filled each spoon half full and placed it in the resident's mouth. During the meal the resident was remained very lethargic and weak. He had to be frequently awakened and cued to swallow by the COTA. Resident #11 mumbled that the food was "hurting" his stomach. COTA T stopped attempted to get the resident to eat and did not offer any fluids. Even with the total assistance and frequent cueing, Resident #11 only consumed: Thickened cranberry juice - 7 half spoonfuls Pudding - 8 half spoonfuls Creamed spinach - 1 half spoonful Cobbler - 3 half spoonfuls Potatoes (fortified) - 5 half spoonfuls Milkshake (fortified) - 1 half spoonful During the meal observation, Resident #11 did not drink any of the thickened water offered. Resident #11 did not eat any of the baked chicken included in the meal. During and after the meal observation, the resident was not offered a nutrition shake or substitute. At 12:40 p.m., the COTA left the therapy department to return the resident to his room. An interview with COTA T at that time revealed Resident #11 routinely ate less than 25% of each meal. COTA T revealed Resident #11 became very fatigued when trying to eat. The COTA explained the meal assistance was part of his therapy regimen for swallowing, and she thought the resident needed an appetite stimulant medication. Review of the July 2012 Flow Sheet revealed Resident #11 ate "bites" at lunch on 07/31/12. Resident #11 was observed on 08/01/12 at 8:55 a.m. in his chair at the table in the ADR. fumbling with a glass of shake. His tray was sitting in front of him. By 9:07 a.m. the resident had fallen asleep without ever accomplishing getting his glass. CNA N awakened the resident and began to feed him. On his tray was a bowl of oatmeal that was now congealed. Resident #11 continued to nod off to sleep between the CNA's attempts to get him to eat. Between his napping, Resident #11 attempted to pick up a cup of juice, but was unsuccessful. CNA N was fed two spoons of the cold oatmeal. The CNA placed a straw in a shake that was on the resident's tray and handed it to him. The CNA made no other attempt to get the resident to eat. The resident was not offered the egg or sausage on his plate. The resident ate all the food that was offered. As CNA N was removing the resident from the ADR at 9:15 a.m., the CNA informed the resident she was taking him to get some toast. CNA N returned the resident to his room but was not observed to provide him with toast or any other food. Review of the July 2012 Flow Sheet revealed Resident #11 ate "fair" (50%) at breakfast on 08/01/12. (Note: This documentation for was the meal observed and the resident ate two spoons of oatmeal and half of a fortified shake.) Review of the facility undated Food Intake Guide posted in the facility dining room for determination of food intake revealed: ? Inadequate - 50%, half of meal was eaten and 4 oz. beverage; ? Very Poor - 25%, very little was eaten, ate only 1 food, 2 oz. beverage and ? Refused - 0-10% ate only 1 or 2 bites, nothing eaten, 0 oz. beverage. Resident #11 was in the ADR for lunch on 08/01/12 at 1:12 p.m. The frail resident was still very lethargic and had to be awaken between bites. CNA N fed him the pureed meal. His intake was the following: Thickened cranberry juice - 5 oz; Meat - 2 small spoonfuls; Pasta - 2 small spoonfuls; Potatoes (fortified) - 3 small spoonfuls; Pudding - 2 small spoonfuls; and Asparagus - 0 spoonfuls. CNA N removed the resident from the ADR and informed the resident she was taking him to get his favorite shake. CNA N placed him in the Bistro near Station II at 1:30 p.m. She gave the resident a chocolate shake and did not stay to encourage his intake, but returned to the ADR to assist other residents. On 08/01/12 at 1:30 p.m. CNA N stated Resident #11 "usually ate a good breakfast but he did not eat as much at other meals." At 1:45 p.m. on 08/01/12, Resident #11 was observed sitting in the Bistro asleep and was holding the chocolate shake he had been given earlier by CNA N. The resident was not being monitored by staff while in the day area. The surveyor observed the resident had consumed approximately 50% of the shake without supervision. The surveyor awakened the resident and offered encouragement. The resident then drank an additional 25% of the shake. At that time, RA G came into the day area, discarded the shake and returned the resident to his room. On 08/02/12 at 8:35 a.m., Resident #11 was observed in his room waiting for breakfast. CNA N was observed picking up trays from other residents on the hall who had completed their meals. CNA N stated Resident #11 was going to be fed breakfast in his room when she was finished picking up the trays of the other residents who had already eaten. CNA N then retrieved Resident #11's breakfast from the delivery cart and took the tray into his room. She stated she would contact the surveyor when the resident was finished eating. An interview with CNA N on 08/02/12 at 9:40 a.m. revealed Resident #11 did not eat any breakfast. CNA N stated she gave the resident a fortified shake but the resident did not drink the shake. She stated the PA was coming today and would assess the resident. Review of Resident #11's Skilled Nurses Note, dated 08/02/12 at 10:00 a.m. revealed LVN U documented, "...poor appetite this a.m. Given 8 oz. Resource 2.0 and consumed at 100%." Review of Resident #11's 2012 Six Month Weight Change Report submitted by the DON on 08/02/12 reflected the following weights in pounds: May 153.0 June 139.5 July 136.7 On 08/03/12 at 5:20 p.m., the DON revealed in May 2012, due to problems identified with weights in the QA meeting, the scales were professionally calibrated. On 08/02/12 at 9:45 a.m. the surveyor requested Resident #11 be weighed due to his poor intake. At 10:00 a.m. Resident #11 was transferred from the geri-chair with a sling to the lift scale and was weighed by RA F an RA G. The resident weighed 111.7 pounds, representing an 18% weight loss since re-admission (15 days). RA F stated the resident was weighed in the lift because, since his fall, he could no longer stand. She stated all of his weights since he started falling were done in the lift. In an interview on 08/02/12 at 10:42 a.m., UM R stated she was not aware of Resident #11's severe weight loss until today when she was told how much he currently weighed (111.7 pounds). She stated the weight difference might be due to the resident being weighed on the lift scale, when previously he was weighed in his wheelchair. UM R stated the resident was currently NPO in preparation for a swallow study. Review of Resident #11's physician's orders [REDACTED]. A order dated 07/23/12 was for ST to evaluate and treat with "focus on dysphagia managment." The resident's diet was change on 07/23/12 to a pureed meal with honey-thicken liquids. An order dated 07/31/12 reflected, "Consult for dysphagia include MBSS." An interview on 08/02/12 at 3:15 p.m. with RA G revealed she conducted weights and documented the values. She stated if there was a significant weight change, she reported the change to the nurse who reported the change to the UM. During an interview on 08/02/12 at 5:20 p.m., the DON stated resident weights were documented on the census sheet, entered into the computer and calculated for weight changes. She stated in the event of significant weight loss or gain, the residents are re-weighed. She stated Resident #11 was re-weighed that day following the 111.7 weight. The re-weigh reflected he weighed 113 pounds (a 17% weight loss since re-admission). In the same interview, the DON stated the facility identified a problem with weight management in May 2012 and determined Dietitian Q was not aggressive enough in the treatment and documentation of intakes for residents with weight changes. The DON stated the scales were checked and calibrated at that time. Resident #11's Re-Admit Comprehensive Nutritional Assessment prepared by Dietitian P on 08/02/12 and submitted by the DON on 08/03/12 for surveyor review and reflected the resident was on a puree, fortified meal plan and received vitamin B12 and Multiple Vitamins with minerals. The assessment further reflected the resident "Feeds Self with Limited Assistance/Verbal Cues." The assessment (using the intakes recorded on CNA Flow Sheets) indicated the resident percent of food intake was "Fair (25-50%)" with the average food intake of 30.95% and his fluid intake was "inadequate." The physical assessment reflected the resident was severely underweight at 113 pounds with a usual weight of 144 pounds. The Weight Status reflected the resident had significant weight loss. The Goals included Resident #11 would continue to eat > 25% of meals and 100% of honey thick house shakes and 100% of fortified milk for weight gain. Review of Resident #11's Dysphagia Evaluation report dated 08/02/12 revealed the resident had Moderate-Severe Dysphagia during the oral phase and Severe Dysphagia during the pharyngeal phase. The resident also had Silent Aspiration. The article, Nutrition and Aging: Assessment and treatment of [REDACTED].ncbi.nlm.nih.gov/pmc/articles/PMC 54/ on 08/17/12 reflected: "In the nursing home setting, a validated tool is the amount of food left on a resident's plate. Residents who have more than 25% of their food remaining on their plate are most likely to suffer from protein undernutrition (Beck et al 2001). One estimate suggests that 84% of nursing home patients had intake less than their calculated daily caloric expenditure, and only 5% were receiving nutritional supplements. Those with lower caloric intake had a higher mortality rate than those whose intake more closely matched their caloric expenditure (Elmstahl et al 1997 </pubmed/ 87>)." 2) Resident #5 was a [AGE] year-old female who had been re-admitted to the facility on [DATE] according to the quarterly MDS assessment dated [DATE]. Her active [DIAGNOSES REDACTED]. She had clear speech, but had some limitation in making concrete requests. The resident had short- and long-term memory problems. The MDS section related to "mood" reflected the resident did not have feeling of depression and did not have a poor appetite. Resident #5's functional status reflected she required "extensive assistance" to eat. The MDS reflected there was "No or unknown" weight loss. The 06/27/12 HCP reflected Resident #5 required total assistance of staff while eating. The approaches included staff were to provide the level of support to complete eating and assist the resident to complete the activity by anticipating her needs. The "DYSPHAGIA" issue related the resident had chewing and swallowing problems and had a "significant weight loss last 30 days, hx (history) of." Approaches included: ? Offer substitute if < (less than) 50% eaten at a meal; ? Monitor appetite and encourage intake at each meal; ? Monitor intake and record percentage eaten at each meal; ? Monitor weight q (every) month and weekly prn (as needed); and ? Allow ample time to ingest meal, staff to feed resident all meals. Resident #5 was observed finishing breakfast that was fed to her by an unidentified CNA while she was in bed on 08/01/12 at 9:00 a.m. It was observed the resident had eaten 35% of her breakfast that included: 100% of her sausage, 50% of the eggs, 50% of a biscuit, two bites (less than 10%) of her oatmeal, 0% of the milk, and 0% of the juice. A Resource 2.0 chocolate supplement on the resident's over-bed table was ? full and warm to-the-touch. The CNA said she was not sure when the resident was provided the supplement. Review of the August 2012 Flow Sheet revealed she ate 50% of the breakfast meal on 08/01/12. Resident #5 was in the ADR for lunch on 08/01/12 at 1:03 p.m. The resident refused the lunch meal and said she was not hungry. The unidentified CNA did not encourage the resident to eat more than two or three times. Resident #5 was observed in her room in bed on 08/02/12 at 8:30 a.m. An unidentified CNA was assisting the resident with her breakfast. It was observed 100% of her sausage and 25% of the eggs were gone from her tray and assumed eaten. The resident had not eaten any of her hot cereal, none of the milk, and none of the juice. The surveyor then left the resident's room. Two minutes later the CNA came out of the room with the tray. Observation of the tray at that time revealed the resident had not eaten anything else. The percentage of the meal eaten was 25%. During the lunch meal on 08/03/12 random observations of the ADR revealed three different staff, including UM I, feeding Resident #5 for approximately one hour. Review of the July 2012 Flow Sheet revealed Resident #5 consumed 25% or less of 26 meals (approximately 1/3 of 93 meals), 50% or less of 31 meals (approximately 1/3 of 93 meals) and 75% or more of 36 meals (approximately 1/3 of 93 meals). Review of Resident #5's Weight Record for the last six months of 2012 revealed the following weights in pounds: May 125.0 June 119.3 July 118.9 On 08/03/12 at 5:20 p.m., the DON revealed in May 2012, due to problems identified with weights in the QA meeting, the scales were professionally calibrated. Upon surveyor request, RA F and RA G weighed Resident #5 on 08/02/12 at 9:30 a.m. in a Hoyer lift. She weighed 111.0 pounds. RA F told the surveyor there were only three aides who weighed residents. Calculation of Resident #5's 2012 weights reflected the following weight loss: July - August 6.6% weight loss; May - August 11.2% weight loss; A telephone order dated 07/27/12 reflected the resident was to have Supercereal with breakfast and was to be put on the Fortified Food Program. A telephone order on 07/24/12 reflected a new order for a pressure sore. The previous Dietitian Q documented on 06/07/12, "Res (resident) wt (weight) has 4.5% decrease x (times) 30 days .... Increase Resource 2.0 to 6 oz. (ounces) QID (four times a day) x 30 days, Resource 4 oz after 30 days. Continue to monitor wt status and PO (by mouth) intake." The current Dietitian P was interviewed on 08/02/12 at 10:30 a.m. She reported she had been hired as the Corporate Dietitian and had been coming to the facility since May 2012. Dietitian P was queried regarding Resident #5's nutritional status and the resident's food likes and dislikes. Dietitian P checked with the Food Service Supervisor (FSS) and found the FSS had talked with the resident when she had been admitted [DATE]. Dietitian P further revealed the resident was receiving a multivitamin but no appetite stimulant, zinc or additional vitamins. The DON was interviewed on 08/02/12 at 10:59 a.m. She said a CNA had weighed Resident #5 and told her the resident's "weight was down." The DON stated she did not know what the weight was. When queried about the weighing process for resident, the DON reported all residents were weighed by the 5th of every month. She said she input the weights into computer and loss or gain was computed. She stated the Weight Committee met to discuss residents who experienced weight loss. Resident #5's nurse, LVN E, was interviewed on 08/02/11 at 11:31 a.m. She reported she was not aware Resident #5 had been weighed the previous afternoon or that she had experienced a weight loss. She said weights were taken at the beginning of the month for all residents and the UM gets the weights. She related the CNAs let her know if residents do not eat. She stated she "really has to work with her (Resident #5) to drink the supplement if she does not eat. She really likes strawberry. She will usually drink it, but only ?, not all of it." UM I was interviewed on 08/02/12 at 11:42 a.m. She said she was not aware Resident #5 had any weight loss. She told the surveyor all residents were weighed by the 5th of the month. The DON put weights into the computer and then gave them to the managers. She revealed they had the "weight meeting" on the Tuesday after the 5th of the month. UM I stated she knew Resident #5 was not eating well. She said she was the one who added the order for fortified foods and super cereal to increase her calories. RA F was interviewed on 08/02/12 at 1:20 p.m. She reported she had weighed Resident #5 yesterday about 5:00 p.m. She said the resident weighed 111.3 pounds. She also said she had told the DON. A nutrition progress note dated 08/02/12 reflected an evaluation of Resident #5's labs, weight loss, medications, and supplements and included "[MEDICATION NAME] 7.5 mg started today." In addition, Dietitian P interviewed the resident to determine what she would like to eat. New recommendations included a Magic Cup with lunch and dinner for 45 days and weekly weights for eight weeks. Review of 08/02/12 nursing notes reflected new orders for: [MEDICATION NAME] 7.5 mg at night for one week, then increase to 15 mg; Resource 2.0 6 oz. four times a day; Vitamin C 500 mg two times a day; Zinc 220 mg every day; and [MEDICATION NAME] one packet every day. The Nurse Practitioner notes reflected Resident #5 was seen because of "weight loss, wound, MS, and elev (elevated) Platelet count" on the evening of 08/02/12. Additional [DIAGNOSES REDACTED]. "Weight loss will be unavoidable due to her end-stage MS/Adult FTT; however, we will start her on [MEDICATION NAME] and [MEDICATION NAME] STAT (immediately) & q 2 wks...Hospice consult will be discussed with RP (Responsible Party) vs PEG (feeding tube)." 3) On 08/02/12 at 5:50 p.m., an IJ was identified in the area of Quality of Care. At that time, the ADM and DON were informed of the IJ and a Plan of Removal was requested. 4) The facility Plan of Removal dated 08/03/12 was accepted and reflected the following: " 1. Facility staff will weight all current residents. These weights will be evaluated for weight loss by the DON. Weight losses will be reported to the physician and the Registered and Licensed Dietician. Residents with weight losses will be evaluated by the dietician who will make recommendations based on their medical conditions and histories. The physician will be notified of all recommendations and all approved interventions will be implemented immediately. This will be completed by August 3rd, 2012. 2. All facility staff will be re-educated regarding providing appropriate levels of assistance for food intakes, accurate documentation of meal intakes, and engaging in conversation, providing cues and encouragement, providing meal set up and offering alternates when appropriate. Licensed staff will be re-educated to notify charge nurse if resident eats less than 50%. If resident eats less than 50%, charge nurse will intervene and attempt to get the resident to finish meal, alternative and or provide supplement. Nursing staff will be re-educated to notify MD of pattern of poor meal intake, to place the resident on weekly weights, and to notify the dietician, DON and family. This education will be compete on 8/3/12. Any staff member who did not attend the education will not be allowed to work until this education is completed. 3. Residents requiring assistance with meal intake will receive their meals first in the dining room starting 8/2/12. Administrative staff will be scheduled to monitor meal service compliance on the weekends. 4. Standards of care committee will meet weekly to review all residents with significant weight loss and evaluate effectiveness of interventions. Plans will be revised as necessary with the assistance of the dietician and the physician. The meeting will be 8/2/12. 5. Management team will meet, discuss and implement this plan before the end of day August 2, 2012." The Plan of Removal also included specific actions for Residents #5 and #11. 5) On 08/03/12 between 12:00 p.m. and 5:30 p.m. surveyors interviewed 10 staff concerning their actions/responsibilities of residents who ate poorly. Nine of 10 staff verbalized knowledge of a recent in-service related to what they should do if residents ate 50% or less of their meal. During an interview on 08/03/12 at 12:18 p.m., LVN E stated the DON had in-serviced the nursing staff "this morning. She told us to notify her if a resident eats less than 50% meal, to offer supplements and make sure the feeders are in the dining room. We are to document the percent eaten on their meal tickets. The charge nurses get the meal tickets after each meal and look at how much each of our residents receive." During an interview on 08/03/12 at 1:00 p.m., the DON stated their Quality Assurance (QA) discovered a general weight problem in May 2012. She stated, "We are currently addressing the problem and I am doing in-services with the staff to instruct them how to properly weigh residents, how to feed and prepare food in the dining room. The dietary concerns we identified months ago. I think that we need to rearrange the way the furniture is in the feeding room. It's not a lack of staff in the dining room; it's the way the residents are fed. Poor timing. Everyone is in there at the same time." During an interview with the DON on 08/03/12 at 2:00 p.m. related to how she ensured that the nursing staff received training to care for the individual residents, she stated that the nurses, CNAs, and MAs were oriented upon hire in the on-line Silver Chair care courses. "These courses consisted of 10 hours of training on activities of daily living and basic care courses in the Silver Chair system. Then they have one full day in the classroom to learn how to use the Accu-Nurse program. We've been using this program for about 2 years. Then we had the weight program added about 1 ? months ago. The nursing staff uses the Point of Care documentation through the head set. The Accu-Nurse program leads them through various prompts. It's first put in as documentation and then the charge nurses and the Care Plan Coordinator will revise it if an alert comes up in the system. It reminds all the different staff about what needs to be done individually for each resident, such as showers, treatments, and toileting. So nothing gets missed. After they get the initial 10 hours of training with the on-line courses, they have one full day of classroom going through the new employee orientation program and basic care." Continued interview with the DON on 8/03/2012 at 2:00 p.m. revealed that the facility had discovered a problem with meal intake percentages. She stated, "Every month we run all the ADL Plans of Care and they get reconciled individually. During PI (Performance Improvement) in May (2012) we found an alert for the food intake, the charge nurses see the alert and they have to address it in the program. I am currently in-servicing all the nursing staff on how to properly do the weights; how to feed and prepare food in the dining room. We are still in the process. It has been a dietary concern. We had identified it months ago. I think that we need to rearrange the way we feed the residents. Along with the PI with weight loss we found other issues related to weights, like making sure the kitchen was getting the diets right, desserts and dining service was at the end of the list. We needed to be sure that a supervisor was in the dining room the entire meal. We found desserts were not being handed out to all the residents, because they were on a separate cart. So we re-educated the nurses, and we have them hand out the desserts with the meals now." On 08/03/12 at 3:40 p.m., the surveyor asked the ADM what systems the facility had in place to ensure residents' quality of care needs were being met. The ADM stated the facility conducted morning meetings and weekly Standards of Care meetings at which time they discussed key areas of care, to include QIs (Quality Indicators), targeted QIs, incidents/accidents, weight loss/nutrition, and pharmacy issues. Facility staff in attendance, including therapy, looked at trends in the areas reviewed. During the interview, the surveyor asked the ADM how he monitored the DON to ensure the systems being monitored were carried out effectively, he stated he was "not a nurse," but he observed residents to make sure they looked alright. He stated that he could

Based on observation, interview and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for two (Residents #5 and #11) of 22 residents reviewed for nutritional parameters. 1. Resident #11 was readmitted on [DATE] following a [MEDICAL CONDITION] with surgical repair. His weight on readmission was 136.7 pounds. On 08/02/12, 15 days later and after surveyor's intervention, Resident #11 was weighed at 111.7 pounds, representing a 25 pound weight loss (18%). 2. Resident #5's intake was not accurately monitored, she was not provided encouragement for meal intake or offered substitutes as per her plan of care. Between July and August 2012, Resident #5 had a 6.6% weight loss. An Immediate Jeopardy (IJ) was identified on 08/02/12. While the IJ was removed on 08/03/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring its Plan of Removal. These failures contributed to the significant/severe weight loss of Residents #5 and #11 and could affect the 18 residents identified by the facility with body weight/nutritional concerns. Findings included: 1. Resident #11 was an [AGE] year-old male who was readmitted to the facility on [DATE] according to the resident's significant change MDS assessment dated [DATE]. His active [DIAGNOSES REDACTED]. Resident #11 had short term and long term memory deficits with severely impaired decision-making ability. His ability to make concrete requests was limited and he responded adequately only to simple, direct communication. Resident #11 frequently had episodes of difficulty concentrating. The assessment reflected the resident did not have a poor appetite. Review of Skilled Nurses Notes dated 07/18/12 revealed Resident #11 was hosptalized on [DATE] due to a fall and subsequent [MEDICAL CONDITION]. The resident returned to the facility on [DATE]. His admission weight was 136.7 pounds. Review of the resident physician's orders [REDACTED]." The most recent HCP dated 07/24/12 reflected Resident #11 required the assistance of one person for all other ADLs, including eating. The goals included to maintain the resident's current weight during the next 90 days. Approaches to the goals included: ? Assess for difficulty chewing/swallowing and refer to ST as indicated; ? Assist with meals as needed; ? Provide snacks between meals; ? Dietary consult for nutritional assessment; ? Monitor appetite and encourage intake at each meal; ? Offer substitue if < 50% eaten at a meal; ? Provide supplement as ordered; and ? Monitor weight q month and weekly as needed. No other concerns associated with nutrition were addressed in this HCP. On 07/31/12 at 9:35 a.m., Resident #11 was observed in a geri-chair being pushed to his room by staff. The resident was very lethargic and seemed weak and fatigued. The resident's arms were exposed and appeared every thin with little muscle mass. UM R revealed at that time that Resident #11 was fed by staff and he had a significant weight loss. UM R stated the resident had a surgical site on his leg due to a recent hospitalization for a [MEDICAL CONDITION]. She stated the surgery site was healing. UM R stated the resident was working with therapy but was unable to bear weight on his leg since his surgery. Resident #11's lab reports were reviewed for nutritional parameters and revealed the most current lab values were dated 03/13/12. The nutritional parameters at that time reflected: Blood Glucose - 68 (normal 70 - 110 mg/dL); Total Protein - 5.4 (normal 6.4 - 8.2 g/dL); and [MEDICATION NAME] - 3.0 (normal 3.4-5.0 g/dL). No pre-[MEDICATION NAME] or iron levels were reflected in the lab report. Resident #11 was observed on 07/31/12 at 12:15 p.m. in the ADR. He was seated at a horseshoe dining table facing the wall. A glass of thickened cranberry juice was on the table in front of him. Resident #11 nodded off to sleep. At 12:25 p.m. on 07/31/12, the resident's tray with a pureed diet with thickened liquids was placed in front of him. The resident was immediately awaken and propelled to the therapy room. The resident appeared dis-interested and fell back to sleep during the trip. At 12:30 p.m. in the therapy department, the resident was placed at a table where he attempted to feed himself but was too weak to hold the spoon. An individual, identified as a therapy student, attempted to feed the resident while attempting to stimulate his swallow reflex by rubbing his throat. Resident #11 remained extremely lethargic and could not stay awake. With each attempt to feed, the resident had to be awakened and cued to swallow each bite offered. The student managed to get the resident to eat in small spoonfuls, one spoon of spinch, two spoons of pudding and one spoon of fortified potatoes. The student left the resident at that time. At 12:38 p.m., COTA A attempted to feed Resident #11. The COTA filled each spoon half full and placed it in the resident's mouth. During the meal the resident was remained very lethargic and weak. He had to be frequently awakened and cued to swallow by the COTA. Resident #11 mumbled that the food was "hurting" his stomach. COTA T stopped attempted to get the resident to eat and did not offer any fluids. Even with the total assistance and frequent cueing, Resident #11 only consumed: Thickened cranberry juice - 7 half spoonfuls Pudding - 8 half spoonfuls Creamed spinach - 1 half spoonful Cobbler - 3 half spoonfuls Potatoes (fortified) - 5 half spoonfuls Milkshake (fortified) - 1 half spoonful During the meal observation, Resident #11 did not drink any of the thickened water offered. Resident #11 did not eat any of the baked chicken included in the meal. During and after the meal observation, the resident was not offered a nutrition shake or substitute. At 12:40 p.m., the COTA left the therapy department to return the resident to his room. An interview with COTA T at that time revealed Resident #11 routinely ate less than 25% of each meal. COTA T revealed Resident #11 became very fatigued when trying to eat. The COTA explained the meal assistance was part of his therapy regimen for swallowing, and she thought the resident needed an appetite stimulant medication. Review of the July 2012 Flow Sheet revealed Resident #11 ate "bites" at lunch on 07/31/12. Resident #11 was observed on 08/01/12 at 8:55 a.m. in his chair at the table in the ADR. fumbling with a glass of shake. His tray was sitting in front of him. By 9:07 a.m. the resident had fallen asleep without ever accomplishing getting his glass. CNA N awakened the resident and began to feed him. On his tray was a bowl of oatmeal that was now congealed. Resident #11 continued to nod off to sleep between the CNA's attempts to get him to eat. Between his napping, Resident #11 attempted to pick up a cup of juice, but was unsuccessful. CNA N was fed two spoons of the cold oatmeal. The CNA placed a straw in a shake that was on the resident's tray and handed it to him. The CNA made no other attempt to get the resident to eat. The resident was not offered the egg or sausage on his plate. The resident ate all the food that was offered. As CNA N was removing the resident from the ADR at 9:15 a.m., the CNA informed the resident she was taking him to get some toast. CNA N returned the resident to his room but was not observed to provide him with toast or any other food. Review of the July 2012 Flow Sheet revealed Resident #11 ate "fair" (50%) at breakfast on 08/01/12. (Note: This documentation for was the meal observed and the resident ate two spoons of oatmeal and half of a fortified shake.) Review of the facility undated Food Intake Guide posted in the facility dining room for determination of food intake revealed: ? Inadequate - 50%, half of meal was eaten and 4 oz. beverage; ? Very Poor - 25%, very little was eaten, ate only 1 food, 2 oz. beverage and ? Refused - 0-10% ate only 1 or 2 bites, nothing eaten, 0 oz. beverage. Resident #11 was in the ADR for lunch on 08/01/12 at 1:12 p.m. The frail resident was still very lethargic and had to be awaken between bites. CNA N fed him the pureed meal. His intake was the following: Thickened cranberry juice - 5 oz; Meat - 2 small spoonfuls; Pasta - 2 small spoonfuls; Potatoes (fortified) - 3 small spoonfuls; Pudding - 2 small spoonfuls; and Asparagus - 0 spoonfuls. CNA N removed the resident from the ADR and informed the resident she was taking him to get his favorite shake. CNA N placed him in the Bistro near Station II at 1:30 p.m. She gave the resident a chocolate shake and did not stay to encourage his intake, but returned to the ADR to assist other residents. On 08/01/12 at 1:30 p.m. CNA N stated Resident #11 "usually ate a good breakfast but he did not eat as much at other meals." At 1:45 p.m. on 08/01/12, Resident #11 was observed sitting in the Bistro asleep and was holding the chocolate shake he had been given earlier by CNA N. The resident was not being monitored by staff while in the day area. The surveyor observed the resident had consumed approximately 50% of the shake without supervision. The surveyor awakened the resident and offered encouragement. The resident then drank an additional 25% of the shake. At that time, RA G came into the day area, discarded the shake and returned the resident to his room. On 08/02/12 at 8:35 a.m., Resident #11 was observed in his room waiting for breakfast. CNA N was observed picking up trays from other residents on the hall who had completed their meals. CNA N stated Resident #11 was going to be fed breakfast in his room when she was finished picking up the trays of the other residents who had already eaten. CNA N then retrieved Resident #11's breakfast from the delivery cart and took the tray into his room. She stated she would contact the surveyor when the resident was finished eating. An interview with CNA N on 08/02/12 at 9:40 a.m. revealed Resident #11 did not eat any breakfast. CNA N stated she gave the resident a fortified shake but the resident did not drink the shake. She stated the PA was coming today and would assess the resident. Review of Resident #11's Skilled Nurses Note, dated 08/02/12 at 10:00 a.m. revealed LVN U documented, "...poor appetite this a.m. Given 8 oz. Resource 2.0 and consumed at 100%." Review of Resident #11's 2012 Six Month Weight Change Report submitted by the DON on 08/02/12 reflected the following weights in pounds: May 153.0 June 139.5 July 136.7 On 08/03/12 at 5:20 p.m., the DON revealed in May 2012, due to problems identified with weights in the QA meeting, the scales were professionally calibrated. On 08/02/12 at 9:45 a.m. the surveyor requested Resident #11 be weighed due to his poor intake. At 10:00 a.m. Resident #11 was transferred from the geri-chair with a sling to the lift scale and was weighed by RA F an RA G. The resident weighed 111.7 pounds, representing an 18% weight loss since re-admission (15 days). RA F stated the resident was weighed in the lift because, since his fall, he could no longer stand. She stated all of his weights since he started falling were done in the lift. In an interview on 08/02/12 at 10:42 a.m., UM R stated she was not aware of Resident #11's severe weight loss until today when she was told how much he currently weighed (111.7 pounds). She stated the weight difference might be due to the resident being weighed on the lift scale, when previously he was weighed in his wheelchair. UM R stated the resident was currently NPO in preparation for a swallow study. Review of Resident #11's physician's orders [REDACTED]. A order dated 07/23/12 was for ST to evaluate and treat with "focus on dysphagia managment." The resident's diet was change on 07/23/12 to a pureed meal with honey-thicken liquids. An order dated 07/31/12 reflected, "Consult for dysphagia include MBSS." An interview on 08/02/12 at 3:15 p.m. with RA G revealed she conducted weights and documented the values. She stated if there was a significant weight change, she reported the change to the nurse who reported the change to the UM. During an interview on 08/02/12 at 5:20 p.m., the DON stated resident weights were documented on the census sheet, entered into the computer and calculated for weight changes. She stated in the event of significant weight loss or gain, the residents are re-weighed. She stated Resident #11 was re-weighed that day following the 111.7 weight. The re-weigh reflected he weighed 113 pounds (a 17% weight loss since re-admission). In the same interview, the DON stated the facility identified a problem with weight management in May 2012 and determined Dietitian Q was not aggressive enough in the treatment and documentation of intakes for residents with weight changes. The DON stated the scales were checked and calibrated at that time. Resident #11's Re-Admit Comprehensive Nutritional Assessment prepared by Dietitian P on 08/02/12 and submitted by the DON on 08/03/12 for surveyor review and reflected the resident was on a puree, fortified meal plan and received vitamin B12 and Multiple Vitamins with minerals. The assessment further reflected the resident "Feeds Self with Limited Assistance/Verbal Cues." The assessment (using the intakes recorded on CNA Flow Sheets) indicated the resident percent of food intake was "Fair (25-50%)" with the average food intake of 30.95% and his fluid intake was "inadequate." The physical assessment reflected the resident was severely underweight at 113 pounds with a usual weight of 144 pounds. The Weight Status reflected the resident had significant weight loss. The Goals included Resident #11 would continue to eat > 25% of meals and 100% of honey thick house shakes and 100% of fortified milk for weight gain. Review of Resident #11's Dysphagia Evaluation report dated 08/02/12 revealed the resident had Moderate-Severe Dysphagia during the oral phase and Severe Dysphagia during the pharyngeal phase. The resident also had Silent Aspiration. The article, Nutrition and Aging: Assessment and treatment of [REDACTED].ncbi.nlm.nih.gov/pmc/articles/PMC 54/ on 08/17/12 reflected: "In the nursing home setting, a validated tool is the amount of food left on a resident's plate. Residents who have more than 25% of their food remaining on their plate are most likely to suffer from protein undernutrition (Beck et al 2001). One estimate suggests that 84% of nursing home patients had intake less than their calculated daily caloric expenditure, and only 5% were receiving nutritional supplements. Those with lower caloric intake had a higher mortality rate than those whose intake more closely matched their caloric expenditure (Elmstahl et al 1997 </pubmed/ 87>)." 2) Resident #5 was a [AGE] year-old female who had been re-admitted to the facility on [DATE] according to the quarterly MDS assessment dated [DATE]. Her active [DIAGNOSES REDACTED]. She had clear speech, but had some limitation in making concrete requests. The resident had short- and long-term memory problems. The MDS section related to "mood" reflected the resident did not have feeling of depression and did not have a poor appetite. Resident #5's functional status reflected she required "extensive assistance" to eat. The MDS reflected there was "No or unknown" weight loss. The 06/27/12 HCP reflected Resident #5 required total assistance of staff while eating. The approaches included staff were to provide the level of support to complete eating and assist the resident to complete the activity by anticipating her needs. The "DYSPHAGIA" issue related the resident had chewing and swallowing problems and had a "significant weight loss last 30 days, hx (history) of." Approaches included: ? Offer substitute if < (less than) 50% eaten at a meal; ? Monitor appetite and encourage intake at each meal; ? Monitor intake and record percentage eaten at each meal; ? Monitor weight q (every) month and weekly prn (as needed); and ? Allow ample time to ingest meal, staff to feed resident all meals. Resident #5 was observed finishing breakfast that was fed to her by an unidentified CNA while she was in bed on 08/01/12 at 9:00 a.m. It was observed the resident had eaten 35% of her breakfast that included: 100% of her sausage, 50% of the eggs, 50% of a biscuit, two bites (less than 10%) of her oatmeal, 0% of the milk, and 0% of the juice. A Resource 2.0 chocolate supplement on the resident's over-bed table was ? full and warm to-the-touch. The CNA said she was not sure when the resident was provided the supplement. Review of the August 2012 Flow Sheet revealed she ate 50% of the breakfast meal on 08/01/12. Resident #5 was in the ADR for lunch on 08/01/12 at 1:03 p.m. The resident refused the lunch meal and said she was not hungry. The unidentified CNA did not encourage the resident to eat more than two or three times. Resident #5 was observed in her room in bed on 08/02/12 at 8:30 a.m. An unidentified CNA was assisting the resident with her breakfast. It was observed 100% of her sausage and 25% of the eggs were gone from her tray and assumed eaten. The resident had not eaten any of her hot cereal, none of the milk, and none of the juice. The surveyor then left the resident's room. Two minutes later the CNA came out of the room with the tray. Observation of the tray at that time revealed the resident had not eaten anything else. The percentage of the meal eaten was 25%. During the lunch meal on 08/03/12 random observations of the ADR revealed three different staff, including UM I, feeding Resident #5 for approximately one hour. Review of the July 2012 Flow Sheet revealed Resident #5 consumed 25% or less of 26 meals (approximately 1/3 of 93 meals), 50% or less of 31 meals (approximately 1/3 of 93 meals) and 75% or more of 36 meals (approximately 1/3 of 93 meals). Review of Resident #5's Weight Record for the last six months of 2012 revealed the following weights in pounds: May 125.0 June 119.3 July 118.9 On 08/03/12 at 5:20 p.m., the DON revealed in May 2012, due to problems identified with weights in the QA meeting, the scales were professionally calibrated. Upon surveyor request, RA F and RA G weighed Resident #5 on 08/02/12 at 9:30 a.m. in a Hoyer lift. She weighed 111.0 pounds. RA F told the surveyor there were only three aides who weighed residents. Calculation of Resident #5's 2012 weights reflected the following weight loss: July - August 6.6% weight loss; May - August 11.2% weight loss; A telephone order dated 07/27/12 reflected the resident was to have Supercereal with breakfast and was to be put on the Fortified Food Program. A telephone order on 07/24/12 reflected a new order for a pressure sore. The previous Dietitian Q documented on 06/07/12, "Res (resident) wt (weight) has 4.5% decrease x (times) 30 days .... Increase Resource 2.0 to 6 oz. (ounces) QID (four times a day) x 30 days, Resource 4 oz after 30 days. Continue to monitor wt status and PO (by mouth) intake." The current Dietitian P was interviewed on 08/02/12 at 10:30 a.m. She reported she had been hired as the Corporate Dietitian and had been coming to the facility since May 2012. Dietitian P was queried regarding Resident #5's nutritional status and the resident's food likes and dislikes. Dietitian P checked with the Food Service Supervisor (FSS) and found the FSS had talked with the resident when she had been admitted [DATE]. Dietitian P further revealed the resident was receiving a multivitamin but no appetite stimulant, zinc or additional vitamins. The DON was interviewed on 08/02/12 at 10:59 a.m. She said a CNA had weighed Resident #5 and told her the resident's "weight was down." The DON stated she did not know what the weight was. When queried about the weighing process for resident, the DON reported all residents were weighed by the 5th of every month. She said she input the weights into computer and loss or gain was computed. She stated the Weight Committee met to discuss residents who experienced weight loss. Resident #5's nurse, LVN E, was interviewed on 08/02/11 at 11:31 a.m. She reported she was not aware Resident #5 had been weighed the previous afternoon or that she had experienced a weight loss. She said weights were taken at the beginning of the month for all residents and the UM gets the weights. She related the CNAs let her know if residents do not eat. She stated she "really has to work with her (Resident #5) to drink the supplement if she does not eat. She really likes strawberry. She will usually drink it, but only ?, not all of it." UM I was interviewed on 08/02/12 at 11:42 a.m. She said she was not aware Resident #5 had any weight loss. She told the surveyor all residents were weighed by the 5th of the month. The DON put weights into the computer and then gave them to the managers. She revealed they had the "weight meeting" on the Tuesday after the 5th of the month. UM I stated she knew Resident #5 was not eating well. She said she was the one who added the order for fortified foods and super cereal to increase her calories. RA F was interviewed on 08/02/12 at 1:20 p.m. She reported she had weighed Resident #5 yesterday about 5:00 p.m. She said the resident weighed 111.3 pounds. She also said she had told the DON. A nutrition progress note dated 08/02/12 reflected an evaluation of Resident #5's labs, weight loss, medications, and supplements and included "[MEDICATION NAME] 7.5 mg started today." In addition, Dietitian P interviewed the resident to determine what she would like to eat. New recommendations included a Magic Cup with lunch and dinner for 45 days and weekly weights for eight weeks. Review of 08/02/12 nursing notes reflected new orders for: [MEDICATION NAME] 7.5 mg at night for one week, then increase to 15 mg; Resource 2.0 6 oz. four times a day; Vitamin C 500 mg two times a day; Zinc 220 mg every day; and [MEDICATION NAME] one packet every day. The Nurse Practitioner notes reflected Resident #5 was seen because of "weight loss, wound, MS, and elev (elevated) Platelet count" on the evening of 08/02/12. Additional [DIAGNOSES REDACTED]. "Weight loss will be unavoidable due to her end-stage MS/Adult FTT; however, we will start her on [MEDICATION NAME] and [MEDICATION NAME] STAT (immediately) & q 2 wks...Hospice consult will be discussed with RP (Responsible Party) vs PEG (feeding tube)." 3) On 08/02/12 at 5:50 p.m., an IJ was identified in the area of Quality of Care. At that time, the ADM and DON were informed of the IJ and a Plan of Removal was requested. 4) The facility Plan of Removal dated 08/03/12 was accepted and reflected the following: " 1. Facility staff will weight all current residents. These weights will be evaluated for weight loss by the DON. Weight losses will be reported to the physician and the Registered and Licensed Dietician. Residents with weight losses will be evaluated by the dietician who will make recommendations based on their medical conditions and histories. The physician will be notified of all recommendations and all approved interventions will be implemented immediately. This will be completed by August 3rd, 2012. 2. All facility staff will be re-educated regarding providing appropriate levels of assistance for food intakes, accurate documentation of meal intakes, and engaging in conversation, providing cues and encouragement, providing meal set up and offering alternates when appropriate. Licensed staff will be re-educated to notify charge nurse if resident eats less than 50%. If resident eats less than 50%, charge nurse will intervene and attempt to get the resident to finish meal, alternative and or provide supplement. Nursing staff will be re-educated to notify MD of pattern of poor meal intake, to place the resident on weekly weights, and to notify the dietician, DON and family. This education will be compete on 8/3/12. Any staff member who did not attend the education will not be allowed to work until this education is completed. 3. Residents requiring assistance with meal intake will receive their meals first in the dining room starting 8/2/12. Administrative staff will be scheduled to monitor meal service compliance on the weekends. 4. Standards of care committee will meet weekly to review all residents with significant weight loss and evaluate effectiveness of interventions. Plans will be revised as necessary with the assistance of the dietician and the physician. The meeting will be 8/2/12. 5. Management team will meet, discuss and implement this plan before the end of day August 2, 2012." The Plan of Removal also included specific actions for Residents #5 and #11. 5) On 08/03/12 between 12:00 p.m. and 5:30 p.m. surveyors interviewed 10 staff concerning their actions/responsibilities of residents who ate poorly. Nine of 10 staff verbalized knowledge of a recent in-service related to what they should do if residents ate 50% or less of their meal. During an interview on 08/03/12 at 12:18 p.m., LVN E stated the DON had in-serviced the nursing staff "this morning. She told us to notify her if a resident eats less than 50% meal, to offer supplements and make sure the feeders are in the dining room. We are to document the percent eaten on their meal tickets. The charge nurses get the meal tickets after each meal and look at how much each of our residents receive." During an interview on 08/03/12 at 1:00 p.m., the DON stated their Quality Assurance (QA) discovered a general weight problem in May 2012. She stated, "We are currently addressing the problem and I am doing in-services with the staff to instruct them how to properly weigh residents, how to feed and prepare food in the dining room. The dietary concerns we identified months ago. I think that we need to rearrange the way the furniture is in the feeding room. It's not a lack of staff in the dining room; it's the way the residents are fed. Poor timing. Everyone is in there at the same time." During an interview with the DON on 08/03/12 at 2:00 p.m. related to how she ensured that the nursing staff received training to care for the individual residents, she stated that the nurses, CNAs, and MAs were oriented upon hire in the on-line Silver Chair care courses. "These courses consisted of 10 hours of training on activities of daily living and basic care courses in the Silver Chair system. Then they have one full day in the classroom to learn how to use the Accu-Nurse program. We've been using this program for about 2 years. Then we had the weight program added about 1 ? months ago. The nursing staff uses the Point of Care documentation through the head set. The Accu-Nurse program leads them through various prompts. It's first put in as documentation and then the charge nurses and the Care Plan Coordinator will revise it if an alert comes up in the system. It reminds all the different staff about what needs to be done individually for each resident, such as showers, treatments, and toileting. So nothing gets missed. After they get the initial 10 hours of training with the on-line courses, they have one full day of classroom going through the new employee orientation program and basic care." Continued interview with the DON on 8/03/2012 at 2:00 p.m. revealed that the facility had discovered a problem with meal intake percentages. She stated, "Every month we run all the ADL Plans of Care and they get reconciled individually. During PI (Performance Improvement) in May (2012) we found an alert for the food intake, the charge nurses see the alert and they have to address it in the program. I am currently in-servicing all the nursing staff on how to properly do the weights; how to feed and prepare food in the dining room. We are still in the process. It has been a dietary concern. We had identified it months ago. I think that we need to rearrange the way we feed the residents. Along with the PI with weight loss we found other issues related to weights, like making sure the kitchen was getting the diets right, desserts and dining service was at the end of the list. We needed to be sure that a supervisor was in the dining room the entire meal. We found desserts were not being handed out to all the residents, because they were on a separate cart. So we re-educated the nurses, and we have them hand out the desserts with the meals now." On 08/03/12 at 3:40 p.m., the surveyor asked the ADM what systems the facility had in place to ensure residents' quality of care needs were being met. The ADM stated the facility conducted morning meetings and weekly Standards of Care meetings at which time they discussed key areas of care, to include QIs (Quality Indicators), targeted QIs, incidents/accidents, weight loss/nutrition, and pharmacy issues. Facility staff in attendance, including therapy, looked at trends in the areas reviewed. During the interview, the surveyor asked the ADM how he monitored the DON to ensure the systems being monitored were carried out effectively, he stated he was "not a nurse," but he observed residents to make sure they looked alright. He stated that he could tell if they had any care issues not being addressed. The ADM stated he met with the DON on a daily basis and the DON had nurse managers working under her. When the Regional Nurse visited, a score card was completed and reviewed with the ADM. The ADM stated everything "drives" through nursing. When the surveyor asked the ADM his opinion on how the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) occurred, he stated he was not blaming anyone. He stated some changes were made, including new people, and maybe the facility was not as "proactive" as they could have been. The ADM stated he did not want to say the facility "screwed up," because he did not believe they did, and that he did not "necessarily agree" with the survey team's findings. During an interview with the DON on 8/03/2012 at 5:15 PM she stated, "We have a monthly QA (Quality Assurance) Committee meeting to review the general systems of the facility, such as laundry, dietary, infection control, and other things that are identified during the prior month as a problem. The Medical Director attends these meetings. We get a QM (Quality Monitoring) report and check it for flags and write an improvement plan mid-month and then review it the next monthly meeting. We take in the Grievance Log and Resident Council Minutes, and we go over the Safety Committee minutes. Our PI is more a custom fit for each individual problem where the QA is more bread spectrum, such as Pharmacy, Admissions and Human Resources. We found weight loss during our mock survey in May (2012). We had the weight scales calibrated, we matched the diet orders to the residents' diets, and we checked meal cards. We did re-training with the restorative aides on how to correctly do the weights. In June (2012) we identified two more PI. We found it was effective because we did see significant improvement from May to July (2012) in the weights. The steps or actions we took for the monthly weights were looking to see if a weight loss triggered, we weigh everyone between the first and fifth of the month. If a weight triggers, we get a speech therapy consult. We checked the table heights they were sitting at in case that made a difference if the food was to high for them to get to. Or we would look at possible other reasons for weight loss such as were they having migraines that would keep them isolated in a dark room, or do they have oral issues, or end of life issues ...we would look at a lot of different things. It was very individualized." The Administrator and DON